2026 MIPS Measure #332: Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)

Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis.

This measure may be submitted based on the actions of the submitting Merit-based Incentive Payment System (MIPS) eligible clinician who performs the quality action, described in the measure, based on services provided within measurespecific denominator coding. This measure is to be submitted a minimum of once per performance period for patients with acute bacterial sinusitis during the performance period.

NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, POS 02, POS 10) are allowable. Please note that effective January 1, 2025, while a measure may be denoted as telehealth eligible, specific denominator codes within the encounter may no longer be eligible due to changes outlined in the CY 2024 PFS Final Rule List of Medicare Telehealth Services.

All patients aged 18 years and older with a diagnosis of acute bacterial sinusitis who are prescribed an antibiotic

Definition:
Acute Bacterial Rhinosinusitis (ABRS) - Acute rhinosinusitis that is caused by, or is presumed to be caused by, bacterial infection. A clinician should diagnose ABRS when: (a) symptoms or signs of acute rhinosinusitis are present 10 days or more beyond the onset of upper respiratory symptoms, or (b) symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening).

Patients aged ? 18 years on date of encounter

AND

Diagnosis for acute sinusitis on date of encounter (ICD-10-CM): J01.00, J01.01, J01.10, J01.11, J01.20, J01.21, J01.30, J01.31, J01.40, J01.41, J01.80, J01.81, J01.90, J01.91

AND

Diagnosis for bacterial and infectious agents (ICD-10-CM): B95.0, B95.1, B95.2, B95.3, B95.4, B95.5, B95.61, B95.62, B95.7, B95.8, B96.0, B96.1, B96.20, B96.21, B96.22, B96.23, B96.29, B96.3, B96.4, B96.5, B96.6, B96.7, B96.81, B96.82, B96.83, B96.89

OR

Sinusitis caused by, or presumed to be caused by, bacterial infection: G9364

AND

Patient encounter during performance period (CPT): 98002, 98003, 98006, 98007, 98010, 98011, 98014, 98015, 98016, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99424, 99491

AND

Antibiotic regimen prescribed: G9498

Patients who were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis

Performance Met: Amoxicillin, with or without clavulanate, prescribed asa first line antibiotic at the time of diagnosis (G9315)

OR

Denominator Exception: Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time of diagnosis for documented reason (G9313)

OR

Performance Not Met: Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time of diagnosis, reason not given (G9314)

The rationale for antibiotic therapy of ABRS is to eradicate bacterial infection from the sinuses, hasten resolution of symptoms, and enhance disease-specific quality of life. Antibiotic therapy should be efficacious, cost-effective, and result in minimal side effects.

The justification for amoxicillin as first-line therapy for most patients with ABRS relates to its safety, efficacy, low cost, and narrow microbiologic spectrum. Consideration to prescribing amoxicillin-clavulanate for adults with ABRS is given to those at a high risk of being infected by an organism resistant to amoxicillin. Factors that would prompt clinicians to consider prescribing amoxicillin-clavulanate instead of amoxicillin include:

Situations in which bacterial resistance is likely (e.g., antibiotic use in the past month; close contact with treated individuals, health care providers, or a health care environment; failure of prior antibiotic therapy; breakthrough infection despite prophylaxis; close contact with a child in a daycare facility; smoker or smoker in the family; high prevalence of resistant bacteria in community)
Presence of moderate to severe infection (e.g., moderate to severe symptoms of ABRS; protracted symptoms of ABRS; frontal or sphenoidal sinusitis, history of recurrent ABRS)
Presence of comorbidity or extremes of life (e.g., comorbid conditions including diabetes; chronic cardiac, hepatic, or renal disease; immunocompromised patient; age greater than 65 years)
The use of high-dose amoxicillin with clavulanate is recommended for adults with ABRS who are at a high risk of being infected with an amoxicillin-resistant organism. High-dose amoxicillin is preferred over standard-dose amoxicillin primarily to cover penicillin non susceptible (PNS) S. pneumoniae. This risk exists in those from geographic regions with high endemic rates (>10%) of invasive PNS S. pneumoniae, those with severe infection (e.g., evidence of systemic toxicity with fever of 39C (102F) or higher, and threat of suppurative complications), age >65 years, recent hospitalization, antibiotic use within the past month, or those who are immunocompromised.