Decoding MIPS in Emergency Medicine – Antibiotic Edition

Revolution in Healthcare

As we all know, we are in the middle of a Revolution of sorts in Health Care.  The practice of medicine is becoming less about the art of medicine and more about the business of medicine.  Patient Satisfaction is a major concern, and satisfaction ratings along with Quality measures, such as MIPS, are going to play a large role in how we are reimbursed by insurance payors.  And when you look at the MIPS guidelines, one of the first questions that comes to mind is ‘How do I satisfy these requirements while keeping my patients happy’? Well, we are going to go over a few of the common MIPS standards here and how you can meet those standards while providing the care that patients want or expect.

MIPS Quality ID #65

The first MIPS Quality measure that we will address is Quality ID #65 – Appropriate Treatment for Children with Upper Respiratory Infection (URI).  This measure is trying to determine the number of children you see and diagnose with URI whom you do not prescribe antibiotics for.  This is because the most common cause for URI (common cold) is viral, which we all know is not treated with antibiotics. The goal is to reduce the prescription of unnecessary antibiotics, thereby decreasing the chance of developing antibiotic resistance and decreasing the overall cost.  But we all have seen children whose parents insist that their child needs a prescription of antibiotics for their cold and will not be happy without one. How do you maintain patient satisfaction and meet this measure?

Well, it is tricky but there are several ways to accomplish both.  The best way is obviously educating the parents about viral versus bacterial infections and why unnecessary antibiotics should be avoided.  I am sure that most people have seen the reports on TV or the internet about antibiotic resistance and “Superbugs”. Sometime you can just explain to the parents that you are trying to protect the child from these resistant organisms by not giving them antibiotics.  Instead, offer them prescriptions for symptomatic relief such as cough medications or oral steroids. If this isn’t effective, there are other ways. You can start by documenting a length of symptoms of 10 days or greater, if they truly have had the symptoms for that long.  At that time, they would qualify for the diagnosis of Acute Bacterial Rhinosinusitis, which would remove them from this quality measure and allow you to prescribe the requested, appropriate, antibiotics.  Another option is to inform the parent that they should try the symptom-relieving medications for 3 days, and if the child has had no improvement or worsening symptoms, then they may require antibiotic therapy at that time.  Coincidentally, if they are prescribed antibiotics after 3 days from the initial visit, then they fall out of this quality standard.

MIPS Quality ID #66

The next MIPS Quality measure that we will tackle is Quality ID #66 – Appropriate testing for Children with Pharyngitis.  This measure is also looking at appropriate use of antibiotics and the use of Rapid Strep tests in the ED or outpatient setting.  Basically, if you have a pediatric patient between the ages of 3 and 18 with a diagnosis of pharyngitis, you should order a rapid strep test.  Notice that the measure doesn’t mention a positive result, only that the test be ordered. You could order the test and discharge the patient as soon as they are swabbed, if that is what you want to do.  As long as you order the test, you may prescribe antibiotics as you deem appropriate. However, if you choose to prescribe antibiotics and not order a Rapid Strep test, be sure you document why. Reasons could be as simple as the patient or family refused, or close contacts recently tested positive for Strep throat and you patient now has similar symptoms and correlating physical exam findings.

MIPS Quality ID #116

While we are on the topic of antibiotic prescribing, lets discuss Quality ID #116 – Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis. This one is similar in intension to the URI in Children measure in that the cause of acute bronchitis in the majority of adults is viral, not bacterial.  However, most patients hear the term “bronchitis” and immediately feel that they need antibiotics, and will not be happy leaving without a prescription. Again, educating your patients about the appropriate need for antibiotics is the best option, and is often very effective.  Offer them steroids and bronchodilators to treat their symptoms and advise them to follow up in 3 days should their symptoms not improve. However, if this doesn’t work, there are ways to still provide “Quality Care” and keep your patient happy. First, if your patient has any form of chronic lung disease such as asthma, COPD, etc, then they are excluded from the measure if you diagnose them with an acute exacerbation of their ailment and document why you feel that they require antibiotic therapy.  The other, less direct way around this standard is to diagnose them with “cough”. The ICD-10 code for this will not trigger inclusion in this measure, so therefore you cannot fall out of the standard.

MIPS Quality ID #331

Lastly, lets discuss two related measures, Quality ID #331 – Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) and Quality ID #332: Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use).  Along with URI and Bronchitis, Acute Sinusitis accounts for a large number outpatient and ER visits every year and represents a large number of inappropriate antibiotic prescriptions.  Because of this, if you prescribe antibiotics for an adult with acute sinusitis it should be documented that the patient has had the symptoms for at least 10 days without improvement, or significant worsening of symptoms in less than 10 days after a period of initial improvement.  Documentation of other medical reason for antibiotic prescription is also acceptable, such as recent sinus instrumentation or surgery. And, if when you do prescribe antibiotics, it should be either plain amoxicillin, or amoxicillin/clavulanic acid. This is because of the relatively low cost, high efficacy against organisms that usually cause Acute Bacterial Sinusitis, narrow spectrum of coverage, and low range of side effects.  Obviously, documented allergy to either medication will remove the patient from this measure, as will documentation demonstrating bacterial resistance to either amoxicillin or amoxicillin/clavulanic acid.

I hope you find this helpful and informative.  In further editions, I will cover some of the other common MIPS Quality Measures that are pertinent to the practice of  Emergency Medicine, and how you can make sure that you stay within those measures. For more information about the MIPS program, you can click here!

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