2026 MIPS Measure #238: Use of High-Risk Medications in Older Adults

Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.

This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. There is no diagnosis associated with this measure. This measure may be submitted by Meritbased 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.

The measure reflects potentially inappropriate medication use in older adults, both for medications where any use is inappropriate and for medications where use under all but specific indications is potentially inappropriate.

This measure will be calculated with 2 performance rates:

Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.
Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class, except for appropriate diagnoses.
For accountability reporting in the CMS MIPS program, the rate for submission criteria 1 is used for performance.

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.

SUBMISSION CRITERIA 1: PERCENTAGE OF PATIENTS 65 YEARS OF AGE AND OLDER WHO WERE ORDERED AT LEAST TWO HIGH-RISK MEDICATIONS FROM THE SAME DRUG CLASS
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

SUBMISSION CRITERIA 2: PERCENTAGE OF PATIENTS 65 YEARS OF AGE AND OLDER WHO WERE ORDERED AT LEAST TWO HIGH-RISK MEDICATIONS FROM THE SAME DRUG CLASS, EXCEPT FOR APPROPRIATE DIAGNOSES
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.

DENOMINATOR (SUBMISSION CRITERIA 1):
Patients 65 years and older who had a visit during the measurement period

Denominator Criteria:
Patients aged ? 65 years on date of encounter

AND

Patient encounter during performance period (CPT or HCPCS): 92002, 92004, 92012, 92014, 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, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99387*, 99397*, G0402, G0438, G0439

AND NOT

DENOMINATOR EXCLUSIONS:

Patients who use hospice services any time during the measurement period: G9741

OR

Patients receiving palliative care during the measurement period: G0034

DENOMINATOR (SUBMISSION CRITERIA 2):
Patients 65 years and older who had a visit during the measurement period

Denominator Criteria:
Patients aged ? 65 years on date of encounter

AND

Patient encounter during performance period (CPT or HCPCS): 92002, 92004, 92012, 92014, 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, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99387*, 99397*, G0402, G0438, G0439

AND NOT

DENOMINATOR EXCLUSIONS:

Patients who use hospice services any time during the measurement period: G9741

OR

Patients receiving palliative care during the measurement period: G0034

HIGH-RISK MEDICATION (HRM) MEASURE – SUMMARY:

SUBMISSION CRITERIA 1 – At least two high-risk medications from same drug class during measurement year:

DEFINITIONS:
- Average Daily Dose: (Quantity of pills × Dose per pill) ÷ Days Supply. Do not round. For elixirs/concentrates: (Volume × Daily Dose) ÷ Days Supply.
- Cumulative Medication Duration: Total number of medication days over a specific period. Counts multiple prescriptions with gaps between them, but does NOT count gaps when medication was not dispensed.

NUMERATOR (CRITERIA 1) – G9368:
Patient ordered at least two high-risk medications from the same drug class during measurement year.

High-risk medication identified by:
1. Table 1 – Any dose, any duration (see list below)
2. Table 2 – >90 days cumulative duration: Nitrofurantoin, Nitrofurantoin macrocrystals-monohydrate
3. Table 3 – Exceeding average daily dose criteria:
- Reserpine > 0.1 mg/day
- Digoxin > 0.125 mg/day
- Doxepin > 6 mg/day

NUMERATOR NOTE: Count patients as numerator-compliant regardless of condition(s) for which medications are ordered.

TABLE 1 – HIGH-RISK MEDICATIONS (Any Dose, Any Duration):
Anticholinergics, first-generation antihistamines:
Brompheniramine, Chlorpheniramine, Cyproheptadine, Dimenhydrinate, Diphenhydramine (oral), Doxylamine, Hydroxyzine, Meclizine, Promethazine, Triprolidine

Anticholinergics, anti-Parkinson agents:
Benztropine (oral), Trihexyphenidyl

Antispasmodics:
Atropine (exclude ophthalmic), Chlordiazepoxide-clidinium, Dicyclomide, Hyoscyamine, Scopolamine

Antithrombotics:
Dipyridamole (oral, excluding extended release)

Cardiovascular, alpha agonists (central):
Guanfacine

Cardiovascular, other:
Nifedipine (excluding extended release)

CNS Antidepressants:
Amitriptyline, Amoxapine, Clomipramine, Desipramine, Imipramine, Nortriptyline, Paroxetine

CNS Barbiturates:
Butalbital, Phenobarbital, Primidone

CNS Vasodilators:
Ergot mesylates

CNS Other:
Meprobamate

Endocrine – Estrogens (oral/topical patch):
Conjugated estrogen, Esterified estrogen, Estradiol, Estropipate

Endocrine – Sulfonylureas, long-duration:
Glimepiride, Glyburide

Endocrine Other:
Desiccated thyroid, Megestrol

Nonbenzodiazepine hypnotics:
Eszopiclone, Zaleplon, Zolpidem

Pain – Skeletal muscle relaxants:
Carisoprodol, Chlorzoxazone, Cyclobenzaprine, Metaxalone, Methocarbamol, Orphenadrine

Pain – Meperidine:
Meperidine

Pain – Other:
Indomethacin, Ketorolac (includes parenteral)

TABLE 2 – HIGH-RISK MEDICATIONS (Days Supply Criteria):
- Nitrofurantoin – >90 days cumulative duration
- Nitrofurantoin macrocrystals-monohydrate – >90 days cumulative duration

TABLE 3 – HIGH-RISK MEDICATIONS (Average Daily Dose Criteria):
- Reserpine > 0.1 mg/day
- Digoxin > 0.125 mg/day
- Doxepin > 6 mg/day

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SUBMISSION CRITERIA 2 – At least two orders of antipsychotics OR benzodiazepines (except for appropriate diagnoses):

DEFINITION:
- Index Prescription Start Date (IPSD): Start date of earliest prescription ordered for a high-risk medication during measurement period.

TABLE 4 – HIGH-RISK MEDICATIONS (Any dose, any duration):

Antipsychotics (first-generation conventional and second-generation atypical):
Aripiprazole, Aripiprazole lauroxil, Asenapine, Brexpiprazole, Cariprazine, Chlorpromazine, Clozapine, Fluphenazine, Haloperidol, Iloperidone, Loxapine, Lurasidone, Molindone, Olanzapine, Paliperidone, Perphenazine, Pimavanserin, Pimozide, Quetiapine, Risperidone, Thioridazine, Thiothixene, Trifluoperazine, Ziprasidone

Benzodiazepines (long, short, and intermediate acting):
Alprazolam, Chlordiazepoxide, Clobazam, Clonazepam, Clorazepate, Diazepam, Estazolam, Lorazepam, Midazolam, Oxazepam, Temazepam, Triazolam

NUMERATOR NOTE (CRITERIA 2):
- Patients with appropriate diagnoses may be excluded – refer to full measure specifications for diagnosis exceptions.

ALIGNMENT:
- This measure aligns with eCQM CMS 156. Providers may review RxNorm codes in applicable eCQM value sets for submission.

KEY TAKEAWAYS:
1. Submission Criteria 1: Any two high-risk meds from same class (Tables 1-3)
2. Submission Criteria 2: Any two antipsychotics OR any two benzodiazepines (Table 4), except appropriate diagnoses
3. Count patients regardless of condition for Criteria 1
4. Average daily dose: Do not round
5. Cumulative duration: Count medication days, NOT gaps between prescriptions

Numerator Options 1:
Performance Met: At least two orders for high-riskmedications from the same drug class (G9367)

OR

Performance Not Met: At least two orders for high-risk medications from the same drug class not ordered (G9368)

Numerator Options 2:
Performance Met: At least two orders for high-risk medications from the same drug class, (Table 4), without appropriate diagnoses (M1209)

OR

Performance Not Met: At least two orders for high-risk medications from the same drug class, (Table 4), not ordered (M1210)

OR

Performance Not Met: Two or more antipsychotic prescriptions ordered for patients who had a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder on or between January 1 of the year prior to the measurement period and the Index Prescription Start Date (IPSD) for antipsychotics (G0032)

OR

Performance Not Met: Two or more benzodiazepine prescriptions ordered for patients who had a diagnosis of seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, or severe generalized anxiety disorder on or between January 1 of the year prior to the measurement period and the IPSD for benzodiazepines (G0033)

Certain medications (MacKinnon & Hepler, 2003) are associated with increased risk of harm from drug side-effects and drug toxicity and pose a concern for patient safety. There is clinical consensus that these drugs pose increased risks in older adults (Kaufman, Brodin, & Sarafian, 2005). Potentially inappropriate medication (PIM) use in older adults has been connected to significantly longer hospital stay lengths and increased hospitalization costs (Hagstrom et al., 2015) as well as increased risk of death (Lau et al. 2004). Use of specific high-risk medications such as hypnotics, including benzodiazepine receptor agonists, and nonsteroidal anti-inflammatory drugs (NSAIDS) can result in increased risk of delirium, falls, fractures, gastrointestinal bleeding and acute kidney injury (Merel et al., 2017). Long-term use of benzodiazepines in older adults has been associated with increased risk of dementia (Zhong et al., 2015; Takada et al., 2016). Additionally, the use of antipsychotics can lead to increased risk of stroke and greater cognitive decline in older adults with dementia (Tampi et al., 2016). Among Medicare beneficiaries it is estimated that the prevalence of PIM use was 77% among long-stay nursing home residents (defined as >101 consecutive days in a nursing home). The most common PIMs were benzodiazepines, antipsychotics, and insulin (Riester et al., 2023).

Older adults receiving inappropriate medications are more likely to report poorer health status at follow-up, compared to those who receive appropriate medications (Lau et al. 2004). A study of the prevalence of potentially inappropriate medication use in older adults found that 40 percent of individuals 65 and older filled at least one prescription for a potentially inappropriate medication and 13 percent filled two or more (Fick et al. 2008). While some adverse drug events (ADEs) are unavoidable, studies estimate that between 30 and 80 percent of ADEs in older adults are preventable (MacKinnon and Hepler 2003). More recently with the onset of the COVID-19 pandemic, several studies have shown an increase in anxiety, insomnia and depression rates, which could result in an increase in the use of highrisk medications in order to treat these conditions (Agrawal, 2020).

Reducing the number of inappropriate prescriptions can lead to improved patient safety and significant cost savings. Conservative estimates of extra costs due to potentially inappropriate medications in older adults average $7.2 billion a year (Fu et al. 2007). Medication use by older adults will likely increase further as the U.S. population ages, new drugs are developed, and new therapeutic and preventive uses for medications are discovered (Rothberg et al. 2008). The annual direct costs of preventable ADEs in the Medicare population have been estimated to exceed $800 million (IOM, 2007). By the year 2030, nearly one in five U.S. residents is expected to be aged 65 years or older; this age group is projected to more than double from 38.7 million in 2008 to more than 88.5 million in 2050. Likewise, the population aged 85 years or older is expected to increase almost four-fold, from 5.4 million to 19 million between 2008 and 2050. As the older adult population continues to grow, the number of older adults who present with multiple medical conditions for which several medications are prescribed will likely continue to increase, resulting in polypharmacy concerns (Gray and Gardner 2009).

REFERENCES:

MacKinnon, N. J., & Hepler, C. D. (2003). Indicators of preventable drug-related morbidity in older adults: Use within a managed care organization. Journal of Managed Care & Specialty Pharmacy, 9(2), 134-141.

Kaufman, M. B., Brodin, K. A., & Sarafian, A. (2005, April/May). Effect of prescriber education on the use of medications contraindicated in older adults in a managed Medicare population. Journal of Managed Care & Specialty Pharmacy, 11(3), 211-219.

Hagstrom, K., Nailor, M., Lindberg, M., Hobbs, L., & Sobieraj, D. M. (2015). Association Between Potentially Inappropriate Medication Use in Elderly Adults and Hospital-Related Outcomes. Journal of the American Geriatrics Society, 63(1), 185-186.

Lau, D.T., J.D., Kasper, D.E., Potter, & A. Lyles. (2004). Potentially Inappropriate Medication Prescriptions Among Elderly Nursing Home Residents: Their Scope and Associated Resident and Facility Characteristics. Health Services Research, 39(5), 1257-1276.

Merel, S.E., & Paauw, D.S. Paauw. (2017). Common Drug Side Effects and Drug-Drug Interactions in Elderly Adults in Primary Care. Journal of the American Geriatrics Society, 65(7), 1578-1585.

Zhong, G., Wang, Y., Zhang, Y., & Zhao, Y. (2015). Association between benzodiazepine use and dementia: a metaanalysis. PLoS One, 10(5).

Takada, M., M. Fujimoto, & K. Hosomi. (2016). Association between benzodiazepine use and dementia: data mining of different medical databases. International Journal of Medical Sciences, 13(11), 825-834.

Tampi, R.R., D.J. Tampi, S. Balachandran, & S. Srinivasan. (2016). Antipsychotic use in dementia: a systematic review of benefits and risks from meta-analyses. Therapeutic Advances in Chronic Disease, 7(5), 229-245.

Riester, M. R., Goyal, P., Steinman, M. A., et al. (2023). Prevalence of Potentially Inappropriate Medication Prescribing in US Nursing Homes, 2013–2017. Journal of General Internal Medicine, 38(6), 1563-1566.Fick, D. M., Mion, L. C., Beers, M. H., et al. (2008). Health outcomes associated with potentially inappropriate medication use in older adults. Research in Nursing & Health, 31(1), 42-51.

Agrawal, R. (2020). Careful Prescribing of Benzodiazepines during COVID-19 Pandemic: A Review. Journal of Mental Health & Clinical Psychology, 4(4). Retrieved from https://www.mentalhealthjournal.org/articles/careful-prescribing-ofbenzodiazepines-during-covid-19-pandemic-a-review.html

Fu, A. Z., Jiang, J. Z., Reeves, J. H., Fincham, J. E., Liu, G. G., & Perri, M. (2007). Potentially Inappropriate Medication Use and Healthcare Expenditures in the US Community-Dwelling Elderly. Medical Care, 45(5), 472–476. Retrieved from http://www.jstor.org/stable/40221449.

Rothberg, M. B., Perkow, P. S., Liu, F., et al. (2008). Potentially inappropriate medication use in hospitalized elders. Journal of Hospital Medicine, 3(2), 91-102.

Institute of Medicine, Committee on Identifying and Preventing Medication Errors. (2007). Preventing medication errors. Aspden, P., Wolcott, J. A., Bootman, J. L., & Cronenwatt, L. R. (Eds.). Washington, DC: National Academy Press.

Gray, C. L., & Gardner, C. (2009). Adverse drug events in the elderly: An ongoing problem. Journal of Managed Care & Specialty Pharmacy, 15(7), 568-571.

The measure is based on recommendations from the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (2023). The criteria were developed through key clinical expert consensus processes by Beers in 1997, Zahn in 2001 and an updated process by Fick in 2003, 2012, 2015 and 2019 and, most recently the American Geriatrics Society Beers Criteria Update Expert Panel in 2023. The Beers Criteria identifies lists of drugs that are potentially inappropriate for all older adults, except for those with certain conditions for which some high-risk medications may be warranted, and drugs that are potentially inappropriate in older adults based on various high-risk factors such as dosage, days’ supply and underlying diseases or conditions. NCQA's Geriatric Measurement Advisory Panel recommended a subset of drugs that should be used with caution in older adults for inclusion in the proposed measure based upon the recommendations in the Beers Criteria.

REFERENCE:

The 2023 American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081.