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Appropriate Treatment for Upper Respiratory Infection (URI)
Measure Information
eCQM Compare View
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| Measure Information | 2023 Performance Period | 2024 Performance Period | 2025 Performance Period | 2026 Performance Period |
|---|---|---|---|---|
| Title | Appropriate Treatment for Upper Respiratory Infection (URI) | Appropriate Treatment for Upper Respiratory Infection (URI) | Appropriate Treatment for Upper Respiratory Infection (URI) | Appropriate Treatment for Upper Respiratory Infection (URI) |
| CMS eCQM ID | CMS154v11 | CMS154v12 | CMS154v13 | CMS154v14 |
| CBE ID* | Not Applicable | Not Applicable | Not Applicable | Not Applicable |
| MIPS Quality ID | 065 | 065 | 065 | 065 |
| Measure Steward | National Committee for Quality Assurance | National Committee for Quality Assurance | National Committee for Quality Assurance | National Committee for Quality Assurance |
| Description |
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 |
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 |
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 |
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 |
| Measure Scoring | Proportion | Proportion | Proportion | Proportion |
| Measure Type | Process | Process | Process | Process |
| Stratification | *See CMS154v11.html |
- 3 months-17 years - 18-64 years - 65 years and older |
- 3 months-17 years - 18-64 years - 65 years and older |
- 3 months-17 years - 18-64 years - 65 years and older |
| Risk Adjustment | *See CMS154v11.html |
None |
None |
None |
| Rationale | *See CMS154v11.html |
Most 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 (Centers for Disease Control and Prevention [CDC], 2020). |
Most 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 (Centers for Disease Control and Prevention [CDC], 2020). |
Most 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 (Centers for Disease Control and Prevention [CDC], 2020). |
| Clinical Recommendation Statement | *See CMS154v11.html |
American Family Physician (Fashner, Ericson, and Werner, 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. |
American Family Physician (Fashner, Ericson, & Werner, 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 (ICSI) (Short et al., 2017) The ICSI work group does not recommend antibiotics for treatment of common cold symptoms in children and adults. |
American Family Physician (Fashner, Ericson, & Werner, 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 (ICSI) (Short et al., 2017) The ICSI work group does not recommend antibiotics for treatment of common cold symptoms in children and adults. |
| Improvement Notation |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
| Definition | *See CMS154v11.html |
None |
None |
None |
| Guidance |
This is an episode of care measure that examines all eligible episodes for the patient during the measurement period. This eCQM is an episode-based measure. 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.
This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
This is an episode of care measure that examines all eligible episodes for the patient. This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients aged 3 months of age and older with a diagnosis of upper respiratory infection from January 1 to December 28 of the measurement period.
This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
This is an episode of care measure that examines all eligible episodes for the patient. This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients aged 3 months of age and older with a diagnosis of upper respiratory infection from January 1 to December 28 of the measurement period.
This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
This is an episode of care measure that examines all eligible episodes for the patient. This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients aged 3 months of age and older with a diagnosis of upper respiratory infection from January 1 to December 28 of the measurement period.
This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| Initial Population |
Outpatient visits, telephone visits, online assessments (i.e. e-visit or virtual check-in), observation stays or emergency department visits with a diagnosis of URI during the measurement period among patients 3 months of age and older |
Outpatient visits, telephone visits, online assessments (i.e., e-visit or virtual check-in), observation stays or emergency department visits with a diagnosis of URI from January 1 to December 28 of the measurement period for patients 3 months of age and older |
Outpatient visits, telephone visits, virtual encounter (i.e., e-visit or virtual check-in), or emergency department visits with a diagnosis of URI from January 1 to December 28 of the measurement period for patients 3 months of age and older |
Outpatient visits, telephone visits, virtual encounter (i.e., e-visit or virtual check-in), or emergency department visits with a diagnosis of URI from January 1 to December 28 of the measurement period for patients 3 months of age and older |
| Denominator |
Equals Initial Population |
Equals Initial Population |
Equals Initial Population |
Equals Initial Population |
| Denominator Exclusions |
Exclude URI episodes when the patient had a comorbid condition during the 12 months prior to or on the episode date. Exclude URI episodes when the patient had an active prescription of antibiotics in the 30 days prior to the episode date but is still active the same day of the encounter. Exclude URI episodes when the patient had competing diagnosis on or three days after the episode date. Exclude URI episodes when the patient had hospice care for any part of the measurement period. |
Exclude URI episodes when the patient had hospice care for any part of the measurement period. Exclude URI episodes when the patient had a comorbid condition during the 12 months prior to or on the episode date. Exclude URI episodes where the patient is taking antibiotics in the 30 days prior to the episode date. Exclude URI episodes where the patient had competing diagnosis on or three days after the episode date. |
Exclude URI episodes when the patient had hospice care for any part of the measurement period. Exclude URI episodes when the patient had a comorbid condition during the 12 months prior to or on the episode date. Exclude URI episodes where the patient is taking antibiotics in the 30 days prior to the episode date. Exclude URI episodes where the patient had competing diagnosis on or three days after the episode date. |
Exclude URI episodes when the patient had hospice care for any part of the measurement period. Exclude URI episodes when the patient had a comorbid condition during the 12 months prior to or on the episode date. Exclude URI episodes where the patient is taking antibiotics in the 30 days prior to the episode date. Exclude URI episodes where the patient had competing diagnosis on or three days after the episode date. |
| Numerator |
URI episodes without a prescription for antibiotic medication on or 3 days after the outpatient visit, telephone visit, online assessment, observation stay or emergency department visit for an upper respiratory infection |
URI episodes without a prescription for antibiotic medication on or three days after the outpatient visit, telephone visit, online assessment, observation stay or emergency department visit for an upper respiratory infection |
URI episodes without a prescription for antibiotic medication on or three days after the outpatient visit, telephone visit, virtual encounter, or emergency department visit for an upper respiratory infection |
URI episodes without a prescription for antibiotic medication on or three days after the outpatient visit, telephone visit, virtual encounter, or emergency department visit for an upper respiratory infection |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
None |
| Denominator Exceptions |
None |
None |
None |
None |
| Telehealth Eligible | Yes | Yes | Yes | Yes |
| Next Version | No Version Available | |||
| Previous Version | No Version Available |
Specifications and Data Elements
General eCQM Information
Additional Resources for CMS154v12
Release Notes
General eCQM Information
Header
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
Updated the rationale based upon more recent literature and evidence to support the measure.
Measure Section: Rationale
Source of Change: Measure Lead
Updated the clinical recommendation statement based upon more recent literature and evidence to support the measure.
Measure Section: Clinical Recommendation Statement
Source of Change: Measure Lead
Updated references.
Measure Section: Reference
Source of Change: Measure Lead
Revised language to collect all data by the end of the measurement period in harmonization with program standards by applying a denominator data collection cap on December 28th of the measurement period.
Measure Section: Guidance
Source of Change: Measure Lead
Revised language to collect all data by the end of the measurement period in harmonization with program standards by applying a denominator data collection cap on December 28th of the measurement period.
Measure Section: Initial Population
Source of Change: Measure Lead
Updated the denominator exclusion language to improve clarity of measure intent, alignment across similar measures and alignment with the logic.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
Refined timing language and standardized it across similar measures.
Measure Section: Numerator
Source of Change: Test Case Review
Updated grammar, wording, and/or formatting to improve readability and consistency.
Measure Section: Multiple Sections
Source of Change: Annual Update
Logic
Updated the order in which denominator exclusions are listed and adjusted definition names to improve clarity of measure intent, alignment across similar measures and alignment with the header.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
Replaced value set Antibiotic Medications for Pharyngitis (2.16.840.1.113883.3.464.1003.196.12.1001) with value set Antibiotic Medications for Upper Respiratory Infection (2.16.840.1.113883.3.464.1003.1190) to capture a different list of appropriate antibiotic medications for this measure.
Measure Section: Numerator
Source of Change: Measure Lead
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section: Definitions
Source of Change: Standards/Technical Update
Updated the version number of the Hospice Library to v5.0.000.
Measure Section: Definitions
Source of Change: Annual Update
Updated the order in which denominator exclusions are listed and adjusted definition names to improve clarity of measure intent, alignment across similar measures and alignment with the header.
Measure Section: Definitions
Source of Change: Measure Lead
Revised the logic to collect all data by the end of the measurement period in harmonization with program standards by applying a denominator data collection cap on December 28th of the measurement period.
Measure Section: Definitions
Source of Change: Measure Lead
Replaced value set Antibiotic Medications for Pharyngitis (2.16.840.1.113883.3.464.1003.196.12.1001) with value set Antibiotic Medications for Upper Respiratory Infection (2.16.840.1.113883.3.464.1003.1190) to capture a different list of appropriate antibiotic medications for this measure.
Measure Section: Definitions
Source of Change: Measure Lead
Removed direct reference code CPT code 99217 from the 'Qualifying Encounters' definition due to terminology update.
Measure Section: Definitions
Source of Change: Measure Lead
Added QDM datatype 'Diagnosis' to the Hospice.'Has Hospice Services' definition referencing a new value set containing SNOMED finding codes to provide an additional approach for identifying patients receiving hospice care.
Measure Section: Definitions
Source of Change: Measure Lead
Added 'day of' specificity to hospice expressions for consistency.
Measure Section: Definitions
Source of Change: Measure Lead
Updated the version number of the Hospice Library to v5.0.000.
Measure Section: Functions
Source of Change: Annual Update
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
Deleted direct reference code CPT code (99217) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Replaced value set Antibiotic Medications for Pharyngitis (2.16.840.1.113883.3.464.1003.196.12.1001) with value set Antibiotic Medications for Upper Respiratory Infection (2.16.840.1.113883.3.464.1003.1190) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Comorbid Conditions for Respiratory Conditions (2.16.840.1.113883.3.464.1003.102.12.1025): Added 4910 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Added 1187 ICD-10-CM codes based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Competing Conditions for Respiratory Conditions (2.16.840.1.113883.3.464.1003.102.12.1017): Added 1 SNOMED CT code (449908004) based on review by technical experts, SMEs, and/or public feedback. Added 9 ICD-10-CM codes (K05.20, K05.211, K05.212, K05.213, K05.219, K05.221, K05.222, K05.223, K05.229) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set (2.16.840.1.113883.3.464.1003.101.12.1010): Renamed to Emergency Department Evaluation and Management Visit based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Value set Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584): Deleted 3 SNOMED CT codes (170935008, 170936009, 305911006) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Hospice Diagnosis (2.16.840.1.113883.3.464.1003.1165) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Hospice Encounter (2.16.840.1.113883.3.464.1003.1003): Added 2 SNOMED CT codes (305911006, 385765002) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Online Assessments (2.16.840.1.113883.3.464.1003.101.12.1089): Added 4 CPT codes (98980, 98981, 99444, 99457) based on review by technical experts, SMEs, and/or public feedback. Added 3 HCPCS codes (G2250, G2251, G2252) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Payer (2.16.840.1.114222.4.11.3591): Added 5 SOP codes (1111, 1112, 142, 344, 141) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Upper Respiratory Infection (2.16.840.1.113883.3.464.1003.102.12.1022): Deleted 1 SNOMED CT code (78337007) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead