CMS154v11 – 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 during the measurement period among patients 3 months of age and older

– DENOMINATOR EXCLUSIONS

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

– NUMERATOR

URI episodes without a prescription for antibiotic medication on or 3 days after the outpatient visit, telephone visit, online assessment, observation stay or emergency department visit for an upper respiratory infection

For Denominator: 

Include patients aged 3 and older at the start of the measurement period with an ‘Encounter with Upper Respiratory Infection’ during the measurement period. The patient should have ‘Upper Respiratory Infection’ diagnosis where the diagnosis starts during or overlaps before the qualifying encounter. To record an encounter, navigate to Patient > Provider Note > eSuperbill. Under the ‘Procedure- CPTs’ heading, enter the encounter code.

To record the diagnosis, use the workflow Patient > Provider Note > Diagnosis. Click ‘Add’ and search for the diagnosis. Add the diagnosis details and click ‘Save’. Then click ‘Accept’ and the diagnosis is added to the provider note.

For Numerator:

Include 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 > eSuperbill.
• To record the diagnosis, use the workflow Patient > Provider Note > Diagnosis.

For Denominator Exclusions:

Exclude patients satisfying any of the following conditions:

• Patients with ‘Encounter with Upper Respiratory Infection’ and hospice care overlapping the measurement period. To document that patient is receiving hospice care outside of a hospital or long term care facility, navigate to Patient > Clinical > Evaluations. Click ‘+ Add’ and search for an intervention. Select ‘Order’ or ‘Performed’ from the ‘Status’ dropdown, then click ‘Sign’ or ‘Save’. 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 with ‘Encounter with Upper Respiratory Infection’ and competing comorbid condition during the 12 months prior to or on the encounter date. To document the comorbid condition, use the workflow Patient > Provider Note > Diagnosis.
• Patients with ‘Encounter with Upper Respiratory Infection’ and competing diagnosis on or three days after the encounter date. To document the competing diagnosis, use the workflow Patient > Provider Note > Diagnosis.
• Patients with ‘Encounter with Upper Respiratory Infection’ and a prescription of antibiotics in the 30 days prior to or on the encounter date. To document the antibiotics, navigate to Patient > Provider Note > Medications. Click ‘Add’ and search for the medication. Enter the medication details and click ‘Save’. Then click ‘Accept’ and the medication is added to the provider note.