CMS 154 Appropriate Treatment for Children with Upper Respiratory Infection (URI): What's New
Greenway Health's Regulatory Resource Hub provides a single-access point for information about regulatory reporting.
Click the following dropdown to see what's new for this measure in 2020.
What's New in 2020
The CMS 154 Appropriate Treatment for Children with Upper Respiratory Infection (URI) measure has been added to Prime Suite Reporting for the 2020 reporting year. This measure reports the percentage of encounters that involved patients who were diagnosed with an upper respiratory infection (URI) and who were not prescribed an antibiotic. Only encounters that involved patients 3 months to 17 years old are counted.
Overview
This measure reports the percentage of encounters that involved patients who were diagnosed with an upper respiratory infection (URI) and who were not prescribed an antibiotic. Only encounters that involved patients 3 months to 17 years old are counted.
This measure counts encounters, not patients.
At a Glance
| eMeasure ID | CMS154v8 |
| NQF | N/A |
| Used For? | Medicaid PI/Stage 3, MIPS (Quality) |
| Domain | Efficiency and Cost Reduction |
| MIPS Quality ID | 65 |
| MIPS Measure Type | Process |
| MIPS High Priority? | Yes |
When documenting a visit in Prime Suite, the best practice is to include only one encounter code per visit. If a visit is associated with more than one encounter code, the QRDA I files you export from PSR 2020 may contain incorrect denominator counts. For 2020 reporting, this affects CMS 146 and CMS 154.
Measure Specification and Value Sets
You should be familiar with this measure’s specification, Value Sets, and direct reference codes (if applicable). Refer to
Identifying Event Times
See Identifying Event Times for important information about the logic this dashboard uses.
Amending Signed Notes
As a best practice, Notes should not be signed until they are finalized. Amending a signed Note (by making changes to it in Prime Suite and then re-saving it) will change a patient’s qualification for this measure. Re-signing the amended Note may allow the patient to qualify again, but only if it is re-signed during the time period required by the measure.
Measure Calculations
| Initial Patient Population | Children age 3 months to 18 years who had an outpatient or emergency department (ED) visit with a diagnosis of upper respiratory (URI) during the measurement period. |
| Denominator | Initial Patient Population |
| Numerator | Children without a prescription for antibiotic medication on or 3 days after the outpatient or ED visit for an upper respiratory infection. |
Measure Details
Initial Population/Denominator
Encounters are counted in the denominator if they involved patients who meet each of the following:
| 1. | They were 3 months – 17 years old at the beginning of the measurement period. Patients who turn 18 years old during the measurement period will qualify. Age is based on the date of birth (DOB) entered on the Information page. |
| 2. | They had at least one non-voided face-to-face encounter during the measurement period. This must be documented in the Plan or E&M section of a Note using a code from one of the following Value Sets: |
- Office Visit
- Emergency Department Visit
- Preventive Care- Initial Office Visit, 0 to 17
- Preventive Care – Established Office Visit, 0 to 17
- Hospital Observation Care – Initial
| 3. | They had a diagnosis of upper respiratory infection (URI) during the visit that qualified them for the criteria #2. This must be documented using a code from the Upper Respiratory Infection Value Set in the Assessment section of Note. |
Denominator Exclusions
Encounters will be excluded from the denominator if they involved patients who meet any of the following. Select a link for additional information.
- They received hospice care.
- They were diagnosed with competing conditions for respiratory conditions.
- They had a prescription for antibiotics.
When documenting in Past Medical History (PMHx) or the Problem List, a Date of Onset must be entered using the mm/dd/yyyyy format. For PMHx, use Code Mapper to ensure that the term you’re using has been mapped to a code from the correct Value Set (Chart > Vocab Admin > Code Mapper > PMHx).
Hospice Care
Patients will be excluded from the denominator if they received hospice care. This must be documented with a vocabulary term in the Results or in a Flowsheet. This documentation must show one of the following:
- They were discharged from the hospital into hospice care during the measurement period. This must be documented with a vocabulary term using a parent code from the Encounter Inpatient Value Set and a child code using either of the following SNOMEDCT version 2019-05-10 direct reference codes:
- 428371000124100, indicating a patient was Discharged to a health care facility for hospice care.
- 428361000124107, indicating a patient was Discharged to home for hospice care.
- They received hospice care. This must be documented with a vocabulary term in a Flowsheet using a code from the Hospice care ambulatory Value Set. The date the provider enters this documentation must occur during the measurement period.
- They had an order for hospice care. This must be documented in the Plan or Results section of a Note using a code from the Hospice care ambulatory Value Set. This order must have been created during the measurement period.
Competing Conditions for Respiratory Conditions
They were diagnosed with competing conditions for respiratory conditions during, or within the three days following, the visit that qualified them for criteria #2. Competing conditions are defined by the Centers for Medicare and Medicaid Services (CMS). They include conditions such as typhoid fever, salmonella, sexually transmitted diseases, or botulism. This diagnosis must be documented using a code from the Competing Conditions for Respiratory Conditions Value Set. This can be indicated by any of the following:
- A diagnosis documented in the Assessment section of a Note.
- An active diagnosis documented in Past Medical History (PMHx) on the Facesheet. The diagnosis must be documented with a valid onset date. Note that if the diagnosis is entered in Past Medical History (PMHx), the diagnosis will remain in the patient's history indefinitely. The only way to end the diagnosis is to add it through the Problem List and enter a resolved date or inactivate it.
- An active, resolved, or inactive diagnosis the Problem List. The diagnosis must be documented with a valid onset date. If resolved, the diagnosis must also have a valid resolved date.
Prescription for Antibiotics
They had a prescription for antibiotics active in the 30 days prior to the visit that qualified them for denominator criteria #2. This must be documented using a code from the Antibiotic Medications for Pharyngitis Value Set in either the Plan section of a Note or the Medication List. The prescription must have been e-prescribed or printed. If the prescription was saved without being e-prescribed or printed, it will not qualify.
Numerator
Encounters are counted in the numerator if they involved patients who were not prescribed an antibiotic during the encounter that qualified for the denominator, or within the three days after the encounter that qualified for the denominator.
Prescriptions for antibiotics are documented using a code from the Antibiotic Medications for Pharyngitis Value Set. This documentation can be made in the Plan section of a Note or on the Medication List. The prescription must have been e-prescribed or printed. If the prescription was saved without being e-prescribed or printed, it will not qualify as a prescribed antibiotic.
Numerator Exclusions
Not Applicable
Denominator Exception
None
