CMS154v12 – Appropriate Treatment for Upper Respiratory Infection (URI)

Outpatient visits, telephone visits, online assessments (i.e., e-visit or virtual check-in), observation stays or emergency department visits with a diagnosis of URI from January 1 to December 28 of the measurement period for patients 3 months of age and older.

A qualifying visit in this case includes:

• Emergency Department Evaluation and Management Visit
• Healthcare Services
• Initial Hospital Observation Care
• Medical Disability Exam
• Observation
• Office Visit
• Outpatient Consultation
• Preventive Care Services Group Counseling
• Preventive Care Services Individual Counseling
• Preventive Care Services, Initial Office Visit, 0 to 17
• Preventive Care, Established Office Visit, 0 to 17
• Preventive Care Services Established Office Visit, 18 and Up
• Preventive Care Services Initial Office Visit, 18 and Up
• Telephone Visits
• Online Assessments
• Unlisted preventive medicine service

– NUMERATOR

URI episodes without a prescription for antibiotic medication on or three days after the outpatient visit, telephone visit, online assessment, observation stay or emergency department visit for an upper respiratory infection

– DENOMINATOR EXCLUSIONS

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

For Denominator: 

• To record an encounter, navigate to Patient > Provider Notes > Create Superbill. Under the ‘Procedure- CPTs’ heading, enter the encounter code.

• To record the diagnosis of URI, use the workflow Patient > Provider Note > Diagnoses. Click ‘Add’ and search for the diagnosis. Add the diagnosis details and click ‘Save’. Then click ‘Accept’ to add the diagnosis to the provider note.

For Numerator:

Patients with an ‘Encounter with Upper Respiratory Infection’ and without a prescription order on or 3 days after the encounter.

• To record an encounter, navigate to Patient > Provider Note > Create Superbill.
• To record the diagnosis, use the workflow Patient > Provider Note > Diagnoses.

For Denominator Exclusions:

• To document that a patient is receiving hospice care outside of a hospital or long-term care facility, navigate to Patient > Provider Note > 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 inpatient encounter, navigate to Patient > Provider Note > Evaluations.

• To document a hospice care assessment, follow the workflow Patient > Provider Note > Evaluations. Click ‘Add’ and search for ‘Hospice Care [Minimum Data Set]’. Then select ‘Performed’ from the ‘Status’ dropdown and ‘Yes’ from the ‘Result’ field.

• A hospice encounter can be documented through Patient > Provider Note > Evaluations or Patient > Provider Note > Create Superbill.
• To record an encounter for patients living long term in nursing homes, head over to Patient > Provider Note > Create Superbill or to Patient > Provider Note > Evaluations. Here, click ‘Add’ and search for the relevant finding.

• To document the:
  • comorbid condition
  • competing diagnosis,

use the workflow Patient > Provider Note > Diagnoses.

• Documentation of patient taking antibiotics can be done through Patient > Provider Note > Medications. Click ‘Add’ and search for the relevant medication. Enter the medication details and click ‘Save’. Then click ‘Accept’ to add it to the provider note.