HEDIS® Tip Sheet

Appropriate Testing for Pharyngitis (CWP)

Measure Description

Percentage of episodes for members 3 years and older where the member was diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode.

Measure Definitions

  • Intake Period: Captures episodes of treatment between July 1 of the year prior to the measurement year to June 30 of the measurement year.
  • Episode Date: The date of service in any outpatient, telephone or ED visit, e-visit or virtual check-in during the intake period with a diagnosis of pharyngitis. 

Compliance

A group A streptococcus test in the 7-day period from 3 days prior to the episode date through 3 days after the episode date.

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Notes

  • Members may have more than one episode during the measurement year. If a member has multiple episodes in a 31-day period, only the first episode will count.
  • Not included in the initial population:
    • Members who had a co-morbid condition during the 365 days prior to or on the episode date.
    • Episode dates where a new or refill prescription for an antibiotic medication was dispensed 30 days prior to the episode date or was active on the episode date.
    • Episode dates that result in an inpatient stay.
    • Episode dates where a person had a claim or encounter with a competing diagnosis on or 3 days after the episode date.
    • Episode dates that did not result in the dispensing of an antibiotic on or up to 3 days after the episode date.
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Exclusions

  • Members in hospice during the measurement year.
  • Members who died during the measurement year.
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Best Practices

  • Perform a rapid strep test or throat culture prior to prescribing antibiotics for patients diagnosed with  pharyngitis.
  • Educate patients on the differences between bacterial and viral infections, including when antibiotic treatment is appropriate and when symptomatic management is recommended.
  • Reinforce the importance of completing the full course of antibiotics as prescribed.
  • Provide guidance on symptom management strategies that can be used at home when antibiotics are not indicated. The CDC's Symptom Relief Prescription Pad is a useful resource to support patient education.
  • Participate in and promote the principles of the Choosing Wisely® campaign to encourage evidence-based care and reduce unnecessary antibiotic use.
  • Ensure consistent messaging regarding appropriate testing and antibiotic use across treatment rooms, patient education materials, organizational websites, and social media platforms.
  • Provide ongoing provider education on evidence-based testing, diagnosis, coding, and antibiotic prescribing practices.
  • When prescribing antibiotics for a condition other than pharyngitis, ensure the diagnosis code submitted accurately reflects the condition being treated to support appropriate measure reporting and documentation.

Antibiotic Medications for CWP





Codes for select competing diagnoses listed below for quick reference (not an all-inclusive list):



Codes for select competing diagnoses listed below for quick reference (not an all-inclusive list):



Codes for select competing diagnoses listed below for quick reference (not an all-inclusive list):



Coding and Benefits Disclaimer

Providers and organizations must submit accurate and complete data in accordance with all billing, coding, and medical policy requirements. HEDIS guidance does not override official coding standards or guarantee reimbursement, as coverage is subject to applicable medical/coding policy and member-specific benefits.

Questions

Should you have specific coding or other questions related to the measure, please send your questions to BlueAlliance@bcbsnd.com.

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Updated 8/28/2026