http://www.cdc.gov/getsmart/campaign-materials/adult-treatment.html
Measure Description:
The percentage of children 2-18 years of age who
were diagnosed with pharyngitis, dispensed an
antibiotic and received a group A streptococcus
(strep) test for the episode. A higher rate represents
better performance (i.e. appropriate testing)
Why This Measure is Important:
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•
Exclusions:
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•
Encounters with > 1 diagnosis
Children with a history of antibiotic Rx within 30
days of encounter
CPT Codes for Outpatient/ED Visits: 99201-99205, 9921199215, 99217-99220, 99241-99245, 99281-99285, 9934199350, 99381-99387, 99391-99397, 99401-99404, 9941199412, 99420, 99429
HCPC Codes for Outpatient Visits: G0402, G0438, G0439,
G0463, T1015
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•
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Documentation Tips:
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UBREV Codes for Outpatient/ED Visits: 0450-0452, 0456,
0459, 0510-0517, 0519-0523, 0526-0529, 0981-0983
ICD9 Codes for Pharyngitis: 034.0, 462, 463
CPT Codes for Streptococcus A test: 87070, 87071, 87081,
87430, 87650 - 87652, 87880
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Best Practice:
Clinical findings do not distinguish Strep pharyngitis from
non-Strep pharyngitis. Perform a rapid strep or throat
culture to confirm a diagnosis of group A streptococcus
(GAS) before prescribing antibiotics.
Please Note: the above codes are utilized by NCQA for HEDIS reporting.
Reimbursement is subject to the provider agreement and member’s
contract. If you have questions, please call the Provider Relations
Department @ 1-800-451-4447 or 570-200-4700
Although only 10% of pharyngitis
diagnoses are bacterial in origin, proper
diagnosis is necessary for correct
treatment plan.
Without antibiotics in the presence of
Strep A, there is an increased risk of
Rheumatic Fever and /or
Glomerulonephritis
Antibiotic treatment is most effective for
hastening resolution of symptoms if
used in the first 2 days of illness.
Treatment with appropriate antibiotics
(usually oral penicillin V unless
contraindicated) is 90% effective at
elimination of Strep A.
If there is a Penicillin allergy,
erythromycin is a recommended
alternative.
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There must be documentation of the
diagnosis of pharyngitis, tonsillitis, or
streptococcal sore throat, the date the
strep test was performed, the result of
the test, and that an antibiotic was
dispensed.
If a throat culture is done along with the
rapid strep test, the lab report should be
placed in the record, or noted in the
progress notes
Make sure to use the right diagnosis
and procedure codes
More information can be found at:
http://www.cdc.gov/getsmart/campaignmaterials/info-sheets/child-pharyngitis.html
and at
http://www.guideline.gov/content.aspx?id=3841
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Blue Cross of Northeastern Pennsylvania is committed to Quality Care for all of its
members. This is accomplished through the use of Best Practice Clinical Guidelines