HEDIS® Tip Sheet

Appropriate Treatment for Upper Respiratory Infection (URI)

Measure Description

Percentage of episodes for members 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic dispensing event.

Measure Definitions

  • Intake Period: Captures eligible episodes of treatment for URI 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 with a diagnosis of upper respiratory infection.
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Notes

  • This measure is reported as an inverted rate, so a higher rate indicates appropriate URI treatment.
    • Compliance for this measure includes events that did not result in an antibiotic being dispensed on or 3 days after the episode date
  • If a member has more than one eligible episode in a 31-day period, only the first eligible episode is included.
  • Include members who had an outpatient visit, ED visit, telephone visit, or telehealth visit for a diagnosis of an upper respiratory infection.
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Best Practices

  • Provide real time bedside education on appropriate antibiotic use.
  • Educate patients on the difference between bacterial and viral infections.
  • 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. Symptom Relief for Viral Illnesses (cdc.gov).
  • Promote and align with the Choosing Wisely campaign.
  • Ensure consistent messaging in treatment rooms, website, and social media platforms regarding appropriate antibiotic use.
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Exclusions

  • Visits that result in an inpatient stay.
  • Members in hospice during the measurement year.
  • Members who died during the measurement year.
  • 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 where the person had a claim/encounter with any diagnosis for a comorbid condition during the 365 days prior to or on the episode date.
  • Episode dates where the person had a claim/encounter with a competing diagnosis on or three days after the episode date.

Exclusion Codes:

Comorbid Conditions

  • ICD-10-CM: A15.0, A17.0, A18.01, A19.0, B44.81, D57.01, D61.810, D70.0, D71, D72.0, D75.81, D76.1, D86.0, E84.0, J22, J41.0, J42, J47.0, J60, J61, J62.0, J63.0, J64, J65, J66.0, J67.0, J68.0, J69.0, J70.0, J80, J81.0, J82, J84.01, J85.0, J86.0, J90, J91.0, J92.0, J93.0, J94.0, J95.00, J95.01, J96.00, J98.51, J99, M05.10, M30.1, M32.13, M33.01, M34.81, M35.02, O98.011, P27.0, Q25.45, Q30.0, Q31.0, Q32.0, Q33.0, Q34.0, Q34.1, Q39.0, Q89.01

Competing Diagnosis

  • ICD-10-CM: A00.0, A02.0, A03.0, A04.0, A05.0, A06.0, A07.0, A08.0, A09, A37.00, A44.0, A50.01, A54.00, A55, A56.00, A57, A58, A59.00, A59.9, A63.0, A64, A69.0, A69.9, B60.0, B64, B78.1, B96.89, E83.2, H66.001, H67.1, H70.001, H95.00, J01.00, J04.10, J05.0, J13, J14, J15.0, J16.0, J17, J18.0, J20.0, J32.0, J35.01, J38.7, J39.0, K05.20, K12.2, L01.00, L03.011, L04.0, L08.1, L92.8, L98.0, M46.20, M89.00, M90.80, N10, N12, N13.0, N15.1, N16, N30.00, N39.0, N41.0, N70.01, N71.0, N72, N73.0, N74, N75.0, N76.0, N77.0, Z20.2, Z22.4, J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91

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