2026 MIPS Measure #277: Sleep Apnea: Severity Assessment at Initial Diagnosis

Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI), a respiratory disturbance index (RDI), or a respiratory event index (REI) documented or measured within 2 months after initial evaluation for suspected obstructive sleep apnea.

This measure is to be submitted a minimum of once per performance period for patients with a diagnosis of sleep apnea seen during the performance period. 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.

All patients aged 18 years and older with an initial diagnosis of sleep apnea

DENOMINATOR NOTE: Denominator eligible encounters only include those where the initial diagnosis of sleep apnea is present in the medical documentation or it is the MIPS eligible clinician’s first encounter with a patient diagnosed with sleep apnea as represented in the coding below.

Patients aged ? 18 years on date of encounter

AND

Diagnosis for sleep apnea on date of encounter (ICD-10-CM): G47.30, G47.33

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, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350

AND
Encounter corresponds to initial diagnosis of sleep apnea or first contact with sleep apnea diagnosed patient: M1441

Patients who had an apnea hypopnea index (AHI), a respiratory disturbance index (RDI), or a respiratory event index (REI) documented or measured within 2 months after initial evaluation for suspected obstructive sleep apnea

Apnea-Hypopnea Index (AHI) – for polysomnography performed in a sleep lab is defined as (Total Apneas + Hypopneas per hour of sleep); “Apnea-Hypopnea Index (AHI)” for a home sleep study is defined as (Total Apneas + Hypopneas per hour of monitoring).

Respiratory Disturbance Index (RDI) – is defined as (Total Apneas + Hypopneas + Respiratory Effort Related Arousals per hour of sleep).

Respiratory Event Index (REI) – is a measure of respiratory events per unit of time for a home sleep apnea test.

NUMERATOR NOTE: The quality data codes below should be used for assessment of a MIPS eligible clinician’s actions within 2 months after the initial evaluation for obstructive sleep apnea. If there is not adequate time for measuring an apnea hypopnea index (AHI), a respiratory disturbance index (RDI), or a respiratory event index (REI) (e.g., initial evaluation was conducted in December of the performance period), report the denominator exception.

Performance Met: Apnea hypopnea index (AHI), respiratory disturbance index (RDI) or respiratory event index (REI) documented or measured within 2 months after initial evaluation for suspected obstructive sleep apnea (G8842)

OR

Denominator Exception: Documentation of reason(s) for not measuring an apnea hypopnea index (AHI), a respiratory disturbance index (RDI), or a respiratory event index (REI) within 2 months after initial evaluation for suspected obstructive sleep apnea (e.g., medical, neurological, or psychiatric disease that prohibits successful completion of a sleep study, patients for whom a sleep study would present a bigger risk than benefit or would pose an undue burden, dementia, patients previously diagnosed with OSA and severity assessed by another provider, patients who decline AHI/RDI/REI measurement, patients who had a financial reason for not completing testing, test was ordered but not completed, patients decline because their insurance (payer) does not cover the expense) (G8843)

OR

Performance Not Met: Apnea hypopnea index (AHI), respiratory disturbance index (RDI), or respiratory event index (REI) not documented or measured within 2 months after initial evaluation for suspected obstructive sleep apnea, reason not given (G8844)

The severity of OSA must be established in order to make an appropriate treatment decision. For patients with obstructive sleep apnea (OSA), treatment selection and implementation are dependent on the severity of the disease. Physicians treating patients with OSA should calculate the patient’s level of severity, which informs risk for other comorbid conditions and complications. Clinically, the apnea-hypopnea index (AHI) provides cutpoints that can be used to establish the diagnosis and severity of OSA and evaluate treatment effect (Cielo et al, 2019). OSA severity is graded depending on the AHI. Mild OSA with AHI of 5 to 30 (Soori et al, 2022). Patients with a respiratory disturbance index equal to or greater than 15 are considered to have moderate to severe OSA and should be treated with OSA therapy.

The Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea recommends that polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA (Kapur et al, 2017).

Mild, moderate and severe OSA are defined according to following criteria in adults: mild, RDI 5 to ?15; moderate, RDI 15 to 30; and severe, RDI >30 (Kushida et al, 2008).

Treatment success is usually defined as a reduction in the AHI/RDI/REI to a specific level (e.g., post-treatment AHI/RDI/REI 50% reduction in AHI/RDI/ REI) (Ramar et al, 2015). The severity of OSA is determined by an index – Apnea Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI), if PSG is performed, or Respiratory Event Index (REI) if out-of-center-sleep testing (OCST) is performed (Goyal et al, 2017).