2026 MIPS Measure #464: Otitis Media with Effusion: Systemic Antimicrobials – Avoidance of Inappropriate Use

Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials.

This measure is to be submitted once for each occurrence of otitis media with effusion (OME) in children seen during the performance period. Each unique occurrence starts with the onset of OME symptoms and concludes with the resolution of OME or after 90 days if a resolution of OME symptoms is not documented. If multiple encounters are documented within an occurrence, Merit-based Incentive Payment System (MIPS) eligible clinicians should submit the most recent encounter during that occurrence. A new occurrence of OME cannot start until the previous occurrence during the performance period has concluded.

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.

All patients aged 2 months through 12 years with a diagnosis of OME

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 aged 2 months through 12 years on the date of the encounter

AND

Diagnosis for OME (ICD-10-CM) on the date of the encounter: H65.90, H65.91, H65.92, H65.93, H65.111, H65.112, H65.113, H65.114, H65.115, H65.116, H65.117, H65.119, H65.191, H65.192, H65.193, H65.194, H65.195, H65.196, H65.197, H65.199, H65.411, H65.412, H65.413, H65.419, H65.491, H65.492, H65.493, H65.499

AND

Patient encounter during the performance period (CPT): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99381*, 99382*, 99383*, 99384*, 99391*, 99392*, 99393*, 99394*

Patients who were not prescribed systemic antimicrobials

Numerator Instructions:
For performance, the measure will be calculated as the number of patients for whom systemic antimicrobials were neither prescribed nor recommended over the number of patients in the denominator (patients aged 2 months through 12 years with a diagnosis of OME). A higher score indicates appropriate treatment of patients with OME (e.g., the proportion for whom systemic antimicrobials were not prescribed).

Performance Met: Systemic antimicrobials not prescribed (G9959)

OR

Denominator Exception: Documentation of medical reason(s) for prescribing systemic antimicrobials (G9960)

OR

Performance Not Met: Systemic antimicrobials prescribed (G9961)

OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic antimicrobials have no proven long-term effectiveness and have potential adverse effects. The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving quality of life (QOL) and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME.