• Pediatric Upper Respiratory Infection (URI): Ages: 3 months-18 yrs. given diagnosis of URI and NOT dispensed an antibiotic prescription


CFHP advocates antibiotic stewardship for our members. Improving antibiotic prescribing is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance. One of the most common conditions where clinicians deviate from best practices for antibiotic prescribing is for the management of upper respiratory infections in children. Barriers to prescribing antibiotics appropriately might include clinician knowledge gaps about best practices and clinical practice guidelines, clinician perception of patient expectations for antibiotics, perceived pressure to see patients quickly, or clinician concerns about decreased patient satisfaction with clinical visits when antibiotics are not prescribed.

CFHP utilizes the National Committee for Quality Assurance (NCQA) for Health Plans HEDIS® Measure of Appropriate Treatment for Children with Upper Respiratory Infection (URI) to assess the provision of evidence-based care for members treated for an upper respiratory infection. This measure evaluates the percentage of children age 3 months–18 years who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription. A higher rate indicates appropriate treatment of children with URI.

Summary of Request:

Pediatric URI is one of the measures included in the CFHP 2019 Primary Care Provider (PCP) Incentive Program for STAR and CHIP lines of business. On a quarterly basis – less than 100% compliance by Primary Care Providers on this measure will result in a loss of one-half (1/2) incentive point for all claims received for this diagnosis where an antibiotic prescription was dispensed.


When antibiotics are prescribed, providers must ensure any secondary diagnoses indicating the need for an antibiotic are submitted on the claim. Episode dates with a claim/encounter with a competing diagnosis on or three (3) days after the Episode Date are excluded from this measure.

Pediatric Upper Respiratory Infection (URI): Ages: 3 months-18 yrs. given diagnosis of URI and NOT dispensed an antibiotic prescription.
ICD-10-CM: J00, J06.0, and J06.9

Provider Notice September 23, 2019


A summary of current national clinical practice guidelines for common outpatient infections in children and adults is available at:…

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