Product Lines:
Advantage MD, EHP, Priority Partners and USFHP.

Eligible Population:
Members 3 years of age and older by December 31 of the measurement year.

Definition:
Percentage of episodes for members ages 3 years and older where the member was diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode.

• A higher rate indicates appropriate testing and treatment.
• Report three age stratifications and total rate:
  • 3–17 years.
  • 18–64 years.
  • 65 years and older.
  • Total. The total is the sum of the age stratifications

Continuous Enrollment:

• 30 days prior to the episode date through 3 days after the episode date (34 total days).

Best Practice and Measure Tips

This measure addresses appropriate treatment for pharyngitis with a strep test and, if appropriate, prescription of an antibiotic within three days of the test.

A pharyngitis diagnosis can be from an outpatient visit, online assessment, telehealth visit, emergency department or observation visit between July 1 of the year prior to the measurement year and June 30 of the measurement year that did not result in an inpatient stay.

Measure Exclusions

Required Exclusion:

• Members in hospice or using hospice services anytime during the measurement year.
• Members who died any time during the measurement year.
• 12 months prior to or on the episode date diagnosis of Comorbid Conditions.

Exclusion Codes:

• Comorbid Conditions
  • ICD-10-CM: A15.0, A17.0, A18.01, A19.0, B44.81, D57.01, D61.810, D70.0, D71, D72.0, D75.81, D76.1, D86.0, E84.0, J22, J41.0, J42, J47.0, J60, J61, J62.0, J63.0, J64, J65, J66.0, J67.0, J68.0, J69.0, J70.0, J80, J81.0, J82, J84.01, J85.0, J86.0, J90, J91.0, J92.0, J93.0, J94.0, J95.00, J95.01, J96.00, J98.51, J99, M05.10, M30.1, M32.13, M33.01, M34.81, M35.02, O98.011, P27.0, Q25.45, Q30.0, Q31.0, Q32.0, Q33.0, Q34.0, Q34.1, Q39.0, Q89.01
    • Additional codes apply.
• Competing Diagnosis
  • ICD-10-CM: A00.0, A02.0, A03.0, A04.0, A05.0, A06.0, A07.0, A08.0, A09, A37.00, A44.0, A50.01, A54.00, A55, A56.00, A57, A58, A59.00, A59.9, A63.0, A64, A69.0, A69.9, B60.0, B64, B78.1, B96.89, E83.2, H66.001, H67.1, H70.001, H95.00, J01.00, J04.10, J05.0, J13, J14, J15.0, J16.0, J17, J18.0, J20.0, J32.0, J35.01, J38.7, J39.0, K05.20, K12.2, L01.00, L03.011, L04.0, L08.1, L92.8, L98.0, M46.20, M89.00, M90.80, N10, N12, N13.0, N15.1, N16, N30.00, N39.0, N41.0, N70.01, N71.0, N72, N73.0, N74, N75.0, N76.0, N77.0, Z20.2, Z22.4
    • Additional codes apply.

Measure Codes

• Group A Strep Test 
  • CPT: 87070, 87071, 87081, 87430, 87650-87652, 87880
• Pharyngitis 
  • ICD-10-CM: J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91

Measure Medications

The following antibiotic medications, in conjunction with a strep test, will meet compliance for this measure:

CWP Antibiotic Medications