Quality ID #66: Appropriate Testing for Pharyngitis

—National Quality Strategy Domain: Efficiency and Cost Reduction

—Meaningful Measure Area: Appropriate Use of Healthcare




Process – High Priority


The percentage of episodes for patients 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic dispensing event and a group A streptococcus (strep) test.


This measure is to be submitted once for each occurrence of pharyngitis during the performance period. Claims data will be analyzed to determine unique occurrences. This measure is intended to reflect the quality of services provided for the primary management of patients with pharyngitis who were dispensed an antibiotic. 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 (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

Measure Submission Type:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.


Outpatient, telephone, online assessment (i.e. e-visit or virtual check-in), observation, or emergency department (ED) visits with a diagnosis of pharyngitis and an antibiotic dispensing event on or within 3 days after the episode date among patients 3 years or older.

Denominator Instructions:

This is an episode of care measure that examines all eligible episodes for the patient during the measurement period. If a patient has more than one eligible episode in a 31-day period, include only the first eligible episode.

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 Criteria (Eligible Cases):

Patients 3 years of age or older on date of encounter


Diagnosis for pharyngitis (ICD-10-CM): J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91


Patient encounter during the performance period (CPT or HCPCS): 98966, 98967, 98968, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99241*, 99242*, 99243*,99244*, 99245*, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*


Prescribed or dispensed antibiotic on or within 3 days after the episode date (Table 1): G8711



Episodes where the patient is taking antibiotics (Table 1) in the 30 days prior to the episode date, or had an active prescription on the episode date.: G9703


Episodes where the patient had a comorbid condition during the 12 months prior to or on the episode date (e.g., tuberculosis, neutropenia, cystic fibrosis, chronic bronchitis, pulmonary edema, respiratory failure, rheumatoid lung disease): G2175


Episodes where the patient had a competing diagnosis on or within three days after the episode date (e.g., intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, acute sinusitis, chronic sinusitis, infection of the adenoids, prostatitis, cellulitis, mastoiditis, or bone infections, acute lymphadenitis, impetigo, skin staph infections, pneumonia/gonococcal infections, venereal disease (syphilis, chlamydia, inflammatory diseases [female reproductive organs]), infections of the kidney, cystitis or UTI): G2097


Patients who use hospice services any time during the measurement period: G9702

Table 1 – Antibiotic Medications

Note: This list should be used when assessing antibiotic prescriptions for the denominator exclusion and numerator components. 

Description Prescription
  • Amoxicillin                       Ampicillin
Beta-lactamase inhibitors
  • Amoxicillin-clavulanate
First generation cephalosporins
  • Cefadroxi
  • Cephalexin
  • Cefazolin
Folate antagonist
  • Trimethoprim
Lincomycin derivatives
  • Clindamycin
  • Azithromycin          Erythromycin ethylsuccinate
  • Clarithromycin        Erythromycin lactobionate
  • Erythromycin          Erythromycin stearate
Natural penicillins
  •  Penicillin G potassium        Penicillin V potassium
  •  Penicillin G sodium            Pencicillin G benzathine
Penicillinase-resistant penicillins
  • Dicloxacillin
  • Ciprofloxacin               Moxifloxacin
  • Levofloxacin                Ofloxacin
Second generation cephalosporins
  • Cefaclor                  Cefuroxime
  • Cefprozil
  • Sulfamethoxazole-trimethoprim
  • Doxycycline               Tetracycline
  • Minocycline
Third generation cephalosporins
  • Cefdinir              Ceftibuten
  • Cefixime             Cefditoren
  • Cefpodoxime    Ceftriaxone


A group A streptococcus test in the seven-day period from three days prior to the episode date through three days after the episode date

Numerator Instructions:

A higher score indicates appropriate treatment of children with pharyngitis (e.g., the proportion for whom antibiotics were prescribed with an accompanying step test).

Numerator Options:

Performance Met: Group A Strep Test Performed (3210F)


Performance Not Met: Group A Strep Test not Performed, reason not otherwise specified (3210F with 8P)