2026 MIPS Measure #66: Appropriate Testing for Pharyngitis

The percentage of episodes for patients 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic order on or within 3 days after the episode date and a group A Streptococcus (Strep) test in the seven-day period from three days prior to the episode date through three days after the episode date.

This measure is to be submitted once for each occurrence of pharyngitis during the performance period. Claims data will be analyzed to determine unique occurrences. This measure is intended to reflect the quality of services provided for the primary management of patients with pharyngitis who were ordered an antibiotic. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

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.

Outpatient, telephone, online assessment (i.e., e-visit or virtual check-in), observation, or emergency department (ED) visits with a diagnosis of pharyngitis or tonsilitis from January 1 to December 28 and an antibiotic order on or within 3 days after the episode date among patients 3 years or older

Denominator Instruction:
This is an episode of care measure that examines all eligible episodes for the patient. The intent is to determine whether antibiotics are being ordered appropriately. Antibiotics should only be ordered if a strep test has been performed to confirm a bacterial infection. Antibiotics should not be ordered for viral infections. Antibiotics should be ordered on the episode date through three days after the episode date.

An episode is defined as each eligible encounter for patients aged 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic order during the measurement period of January 1 to December 28.

If a patient has more than one eligible episode in a 31-day period, include only the first eligible episode.

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

PHARYNGITIS/TONSILLITIS ANTIBIOTIC STEWARDSHIP MEASURE – SUMMARY:

INCLUSION (DENOMINATOR):
- Age: ?3 years on encounter date
- Diagnosis: Pharyngitis or Tonsillitis (J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91)
- Encounter during measurement period using eligible CPT/HCPCS codes (see full list)
- EXCLUDE Place of Service (POS) 21 (Inpatient Hospital)
- REQUIRED: Antibiotic prescribed on or within 3 days AFTER episode date (G8711)

DENOMINATOR EXCLUSIONS (EXCLUDE FROM MEASURE IF ANY):
1. G9703 – Antibiotic use (Table 1) in 30 days PRIOR to episode date
2. G2175 – Comorbid condition in 12 months prior (TB, neutropenia, cystic fibrosis, chronic bronchitis, pulmonary edema, respiratory failure, rheumatoid lung disease)
3. G2097 – Competing diagnosis on or within 3 days after episode (intestinal infection, pertussis, bacterial infection, Lyme, otitis media, sinusitis, adenoid infection, prostatitis, cellulitis, mastoiditis, bone infections, lymphadenitis, impetigo, staph, pneumonia, gonococcal, syphilis, chlamydia, PID, kidney infection, cystitis, UTI)
4. G9702 – Hospice services anytime during measurement period

ANTIBIOTIC CLASSES (TABLE 1) – CHECK FOR EXCLUSION G9703 AND G8711:
- Aminopenicillins (amoxicillin, ampicillin)
- Beta-lactamase inhibitors (amoxicillin-clavulanate)
- Cephalosporins (1st gen: cefadroxil, cefazolin, cephalexin; 2nd: cefaclor, cefprozil, cefuroxime; 3rd: cefdinir, cefixime, cefpodoxime, ceftriaxone)
- Folate antagonist (trimethoprim)
- Lincomycin derivatives (clindamycin)
- Macrolides (azithromycin, clarithromycin, erythromycin)
- Natural penicillins (penicillin G K+, G Na+, VK, benzathine)
- Quinolones (ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin)
- Sulfonamides (sulfamethoxazole-trimethoprim)
- Tetracyclines (doxycycline, minocycline, tetracycline)

KEY TAKEAWAY:
Patient qualifies for measure if age ?3yrs + pharyngitis/tonsillitis Dx + eligible visit + antibiotic prescribed within 3 days AFTER – EXCLUDE if any of G9703 (antibiotic in prior 30d), G2175 (comorbid Dx), G2097 (competing Dx), G9702 (hospice), or POS 21.

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

Numerator Instruction:
A higher score indicates appropriate treatment of children with pharyngitis (e.g., the proportion for whom antibiotics were prescribed with an accompanying Strep test. The test must be performed to confirm a bacterial infection prior to the antibiotic order).

Performance Met: Group A Strep Test Performed (3210F)

OR

Performance Not Met: Group A Strep Test not Performed, reason not otherwise specified (3210F with 8P)

Group A streptococcal (GAS) bacterial infections and other infections that cause pharyngitis (which are most often viral) often produce the same signs and symptoms (Shulman et al., 2012). The American Academy of Pediatrics, the Centers for Disease Control and Prevention, and the Infectious Diseases Society of America all recommend a diagnostic test for Strep A to improve diagnostic accuracy and avoid unnecessary antibiotic treatment (Linder et al. 2005).

Estimated economic costs of pediatric streptococcal pharyngitis in the United States range from $224 million to $539 million per year, including indirect costs related to parental work losses. At a higher level, the economic cost of antibiotic resistance vary but have extended as high as $20 billion in excess direct healthcare costs, with additional costs to society for lost productivity as high as $35 billion a year (2008 dollars) (Pfoh et al., 2008).

Infectious Disease Society of America (2012)

The Infectious Diseases Society of America (IDSA) “recommends swabbing the throat and testing for GAS pharyngitis by rapid antigen detection test (RADT) and/or culture because the clinical features alone do not reliably discriminate between GAS and viral pharyngitis except when overt viral features like rhinorrhea, cough, oral ulcers, and/or hoarseness are present”