2026 MIPS Measure #65: Appropriate Treatment for Upper Respiratory Infection (URI)

Percentage of episodes for patients 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic order.

This measure is to be submitted once for each occurrence of upper respiratory infection during the performance period. Claims data will be analyzed to determine unique occurrences. 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 visits, telephone visits, online assessments (i.e., e-visit or virtual check-in), observation stays or emergency department visits with a diagnosis of upper respiratory infection (URI) from January 1 to December 28 for patients 3 months of age and older

Denominator Instructions:
This is an episode of care measure that examines all eligible episodes for the patient. If the patient has more than one episode in a 31-day period, include only the first episode.

An episode is defined as each eligible encounter for patients aged 3 months of age and older with a diagnosis of upper respiratory infection during the measurement period of January 1 to December 28.

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.

URI ANTIBIOTIC STEWARDSHIP MEASURE – SUMMARY:

INCLUSION (DENOMINATOR):
- Age: ?3 months on encounter date
- Diagnosis: URI (J00, J06.0, J06.9)
- Encounter during measurement period using eligible CPT/HCPCS codes (see full list)
- EXCLUDE Place of Service (POS) 21 (Inpatient Hospital)

DENOMINATOR EXCLUSIONS (EXCLUDE FROM MEASURE IF ANY):
1. G2173 – Comorbid condition in 12 months prior (TB, neutropenia, cystic fibrosis, chronic bronchitis, pulmonary edema, respiratory failure, rheumatoid lung disease)
2. G2174 – Antibiotic use (Table 1) in 30 days prior to URI episode
3. G8709 – Competing diagnosis on or within 3 days after URI (e.g., pertussis, bacterial infection, otitis media, sinusitis, pharyngitis, UTI, pneumonia, cellulitis, etc.)
4. G9700 – Hospice services anytime during measurement period

ANTIBIOTIC CLASSES (TABLE 1) – CHECK FOR EXCLUSION G2174:
- Aminoglycosides (amikacin, gentamicin, streptomycin, tobramycin)
- Aminopenicillins (amoxicillin, ampicillin)
- Beta-lactamase inhibitors (amoxicillin-clavulanate, ampicillin-sulbactam, piperacillin-tazobactam)
- Cephalosporins (1st gen: cefadroxil, cefazolin, cephalexin; 2nd: cefaclor, cefotetan, cefoxitin, cefprozil, cefuroxime; 3rd: cefdinir, cefixime, cefotaxime, cefpodoxime, ceftazidime, ceftriaxone; 4th: cefepime)
- Lincomycin derivatives (clindamycin, lincomycin)
- Macrolides (azithromycin, clarithromycin, erythromycin)
- Miscellaneous (aztreonam, chloramphenicol, dalfopristin-quinupristin, daptomycin, linezolid, metronidazole, vancomycin)
- Natural penicillins (penicillin G K+, G Na+, benzathine, VK, procaine combos)
- Penicillinase-resistant (dicloxacillin, nafcillin, oxacillin)
- Quinolones (ciprofloxacin, gemifloxacin, levofloxacin, moxifloxacin, ofloxacin)
- Rifamycin (rifampin)
- Sulfonamides (sulfadiazine, sulfamethoxazole-trimethoprim)
- Tetracyclines (doxycycline, minocycline, tetracycline)
- Urinary anti-infectives (fosfomycin, nitrofurantoin, nitrofurantoin macrocrystals-monohydrate, trimethoprim)

KEY TAKEAWAY:
Patient qualifies for measure if age ?3mo + URI diagnosis + eligible visit – EXCLUDE if any of G2173, G2174 (antibiotic in prior 30d), G8709 (competing Dx), G9700 (hospice), or POS 21.

URI episodes without a prescription for antibiotic medication (Table 1) on or within 3 days after the outpatient visit, telephone visit, online assessment, observation stay or emergency department visit for an upper respiratory infection

Numerator Instructions:
For performance, the measure will be calculated as the number of patient’s encounter(s) where antibiotics from Table 1 were not prescribed on or within three days of the episode for URI over the total number of encounters in the denominator. A higher score indicates appropriate treatment of patients with URI (e.g., the proportion for whom antibiotics were not prescribed following the episode). Delayed prescriptions (where an antibiotic was prescribed and patient was instructed to delay taking the antibiotic) are considered “Performance Not Met”.

Performance Met: Patient not prescribed antibiotic (G8708)

OR

Performance Not Met: Patient prescribed antibiotic (G8710)

Most upper respiratory infections (URI), also known as the common cold, are caused by viruses that require no antibiotic treatment. Too often, antibiotics are prescribed inappropriately, which can lead to antibiotic resistance (when antibiotics can no longer cure bacterial infections). In the United States, at least 2.8 million antibiotic-resistant illnesses and 35,000 deaths occur each year.

American Family Physician (Fashner, Ericson, and Werner, Khilberg 2012)

- Antibiotics should not be used for the treatment of cold symptoms in children or adults. (A)

- Nonsteroidal anti-inflammatory drugs reduce pain secondary to upper respiratory tract infection in adults. (A)

- Decongestants, antihistamine/decongestant combinations, and intranasal ipratropium (Atrovent) may improve cold symptoms in adults. (B)

Institute for Clinical Systems Improvement (Short, et al, 2017)

-The ICSI work group does not recommend antibiotics for treatment of common cold symptoms in children and adults.