HEDIS® Tip Sheet

Appropriate Testing for Pharyngitis (CWP)

Line of business: BlueAlliance (Commercial) & BlueAlliance Care+ (Medicaid)

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

  • Eligible visits include outpatient visit, ED visit, telephone visit, or telehealth visit for a diagnosis of pharyngitis.
  • 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.
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Best Practices

  • Perform a strep test or throat culture prior to prescribing antibiotics for patients with a diagnosis of pharyngitis.
  • Educate patients regarding difference between bacterial vs. viral, when antibiotics are indicated, and when symptomatic treatment is indicated.
  • Educate patients on importance of taking the full course of antibiotics when prescribed.
  • Educate patients on how to treat symptoms at home without antibiotics. The CDC has a ‘Symptom Relief Prescription Pad’ which can be downloaded from the cdc.gov.
  • Engage in the Choosing Wisely campaign.
  • Provide consistent messaging in treatment rooms, website, and social media platforms regarding appropriate testing and antibiotic use.
  • Ongoing provider education related to appropriate testing and prescribing practices.
  • If treating a patient with antibiotics for another condition, use the diagnosis code corresponding to the illness being treated with the antibiotic.
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Exclusions

  • Members who had a claim/encounter with any competing diagnosis on the episode date through 3 days after the episode date.
  • Members who had a co-morbid condition on or up to 12 months prior to 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 that did not result in the dispensing of an antibiotic on or up to 3 days after the episode date.
  • Members in hospice during the measurement year.
  • Members who died during the measurement year. 

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 Disclaimer

The analysis of any medical coding question related to a measure is dependent on the measure’s technical specifications including the factual situations present related to the member, the practice, the professionals, and the medical services provided.

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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