CMS146v11 – Appropriate Testing for Pharyngitis

Outpatient, telephone, online assessment (i.e. e-visit or virtual check-in), observation, or emergency department (ED) visits with a diagnosis of pharyngitis or tonsillitis and an antibiotic order on or within 3 days after the episode date among patients 3 years or older

– NUMERATOR

A group A streptococcus test in the seven-day period from three days prior to the episode date through three days after the episode date

DENOMINATOR EXCLUSIONS

• Exclude episodes where the patient is taking antibiotics in the 30 days prior to the episode date, or had an active prescription on the episode date.
• Exclude episodes where the patient had a comorbid condition during the 12 months prior to or on the episode date.
• Exclude episodes when the patient had hospice care for any part of the measurement period.
• Exclude episodes where the patient had a competing diagnosis on or within three days after the episode date.

For Denominator:

Include patients aged 3 years and older at the start of the measurement period with an ‘Encounter with Pharyngitis or Tonsillitis’. A qualifying encounter should be recorded with ‘Antibiotic Medications for Pharyngitis’ ordered such that the encounter starts 3 days or less on or before the date of medication order. Moreover, the patient should be diagnosed with acute pharyngitis or acute tonsillitis during the visit.

• Workflow for qualifying encounter: Patient > Provider Note > eSuperbill. Under the ‘Procedure- CPTs’ heading, enter the encounter code.

• Workflow for medication ordered: Patient > Provider Note > Prescription. Click ‘Add’ and search for the prescription. Enter the prescription details and click ‘Save’.

• Workflow for acute pharyngitis or acute tonsillitis diagnosis: Patient > Provider Note > Diagnoses. Click ‘Add’ and search for the diagnosis. Add the diagnosis details and then click ‘Save’.

For Numerator:

Include patients satisfying the following criteria:

• Patients with ‘Encounter with Pharyngitis or Tonsillitis with Antibiotic’. A qualifying encounter should be recorded with ‘Antibiotic Medications for Pharyngitis’ ordered such that the encounter starts 3 days or less on or before the date of medication order. Moreover, the patient should be diagnosed with acute pharyngitis or acute tonsillitis during the visit.
  • Workflow for qualifying encounter: Patient > Provider Note > eSuperbill. Under the ‘Procedure – CPTs’ heading, enter the encounter code.
  • Workflow for medication ordered: Patient > Provider Note > Prescription. Click ‘Add’ and search for the prescription. Enter the prescription details and click ‘Save’.
  • Workflow for acute pharyngitis or acute tonsillitis diagnosis: Patient > Provider Note > Diagnoses. Click ‘Add’ and search for the diagnosis. Add the diagnosis details and then click ‘Save’.
• Patients with a ‘Group A Streptococcus Test’ performed within 3 days of end of ‘Encounter with Pharyngitis or Tonsillitis with Antibiotic’. The result of the lab test must not be null.

To perform a laboratory test, navigate to Patient > Clinical > Orders & Result > Labs to click on the ‘+ Add Order’ button.

Select a Laboratory and search for the lab test. Once done, click on the ‘Save’ button or hover over the ‘Sign’ button. If the user hovers over the ‘Sign’ button, then click ‘Queue’.

Next, click on the ‘Mark as Received’ button.

On the Lab result screen, add the observations and click on the ‘Save’ button.

Note:

Please ensure that the lab code is mapped to a LOINC Code from the Settings. To map a LOINC with the lab code, navigate to Settings > EHR > Laboratory. Select the Lab and navigate to the ‘Code’ tab. Then, click on the Lab Order. Under the ‘Result Codes and LOINCS’ heading, add a Code, LOINC and Description and click on the ‘Add’ button.

Once done, click on ‘Save’. 

When a CPT code is added to a lab order, please ensure that the CPT code is present in the ‘Procedures’.

Moreover, the CPT code should be mapped to a LOINC Code from the Settings. To map a LOINC with the CPT code, navigate to Settings > Billing > Procedure. Select the CPT code and navigate to the ‘Edit Procedure’ tab. Under the ‘Procedure Components’ heading, add a Code, LOINC and Description and click on the ‘Add’ button.

Once done, click on ‘Save’.

For Denominator Exclusions:

Exclude patients fulfilling any of the following conditions:

• Patients satisfying the criteria for denominator and who also received hospice care during the measurement year. To document that patient is receiving hospice care outside of a hospital or long term care facility, navigate to Patient > Clinical > Evaluations. Use the below mentioned codes to order or perform an intervention:
  • 385763009: Hospice Care (Regime/Therapy)
  • 385765002: Hospice Care Management (Procedure)

• • To document an encounter inpatient, navigate to Patient > Clinical > Evaluations

• Patients with hospice care assessment performed during the measurement period. To document the assessment, follow the workflow Patient > Clinical > Evaluations. Click ‘+ Add’ and search for an evaluation. Then select ‘Performed’ from the ‘Status’ dropdown and enter ‘Yes’ in the ‘Result’ field.
• Patients with hospice encounter during the measurement period. To document the hospice encounter, follow the workflow Patient > Clinical > Evaluations.

• Patients taking antibiotics in the 30 days prior to the ‘Encounter with Pharyngitis or Tonsillitis’. Use the workflow, Patient > Provider Note > Medications. Click ‘Add’ and search for the medication. Enter the medication details and click ‘Save’.

• Patients who had a competing comorbid condition during the 12 months prior to or on the date of ‘Encounter with Pharyngitis or Tonsillitis’. To record the diagnosis, use the workflow, Patient > Provider Note > Diagnoses.
• Patients with a competing diagnosis for upper respiratory infection within 3 days after the ‘Encounter with Pharyngitis or Tonsillitis’. The diagnosis and the ‘Encounter with Pharyngitis or Tonsillitis’ should not be on the same day. To record the diagnosis, use the workflow, Patient > Provider Note > Diagnoses.