2026 MIPS Measure #338: HIV Viral Suppression

Percentage of patients, regardless of age, diagnosed with HIV prior to or during the first 90 days of the performance period, with an eligible encounter in the first 240 days of the performance period, whose last HIV viral load test result was less than 200 copies/mL during the performance period.

This measure is to be submitted a minimum of once per performance period for patients with HIV seen during the first 240 days of the performance period. This measure is intended to reflect the quality of services provided for the primary management of patients with HIV. HIV viral load test results may be expressed as log values (log copies/mL). Please convert the log value to copies/mL.

NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, 95, 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, regardless of age, diagnosed with HIV prior to or during the first 90 days of the performance period with at least one eligible encounter in the first 240 days of the performance period

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.

Patients, regardless of age

AND

Diagnosis of HIV prior to the performance period or during the first 90 days of the performance period (ICD-10-CM): B20, B97.35, Z21, O98.711, O98.712, O98.713, O98.719, O98.72, O98.73

AND

Patient encounter during the first 240 days of the performance period (CPT or HCPCS): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98966, 98967, 98968, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99242*, 99244*, 99245*, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, 99429*, G0402, G0438, G0439

Patients with a last HIV viral load test result of less than 200 copies/mL during the performance period

Performance Met: Documentation of viral load less than 200 copies/mL (G9243)

OR

Performance Not Met: Documentation of viral load equal to or greater than 200 copies/mL or viral load not performed (G9242)

“Antiretroviral therapy (ART) has reduced HIV-related morbidity and mortality at all stages of HIV infection and has reduced HIV transmission. Maximal and durable suppression of plasma viremia delays or prevents the selection of drug-resistance mutations, preserves or improves CD4 T lymphocyte (CD4) cell numbers, and confers substantial clinical benefits, all of which are important treatment goals. HIV suppression with ART may also decrease inflammation and immune activation thought to contribute to higher rates of cardiovascular and other end-organ damage reported in cohorts with HIV. Despite these benefits, eradication of HIV infection cannot be achieved with available antiretrovirals (ARVs). Treatment interruption has been associated with rebound viremia, worsening of immune function, and increased morbidity and mortality. Thus, once initiated, ART should be continued, with the following key treatment goals: maximally and durably suppress plasma HIV RNA; restore and preserve immunologic function; reduce HIVassociated morbidity and prolong the duration and quality of survival; and prevent HIV transmission.” (DHHS Adult and Adolescent, 2025)