If your dermatology practice prescribes biologics, TB screening before a patient starts treatment is already part of your clinical routine. What many billers and office managers don't realize is that this same step is also a MIPS reporting opportunity - and if it isn't documented the right way, you won't get credit for it, even if the screening actually happened.
MIPS Measure 176 is one of the more attainable quality measures for dermatology practices. The clinical workflow is already baked into your process. The challenge is knowing exactly when the measure triggers, what needs to be in the chart, and which patients qualify.
What Is MIPS Measure 176?
Measure 176 is formally titled TB Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy. It falls under the Quality performance category and is reported through a Qualified Registry or QCDR.
The measure tracks whether patients received a tuberculosis test within 12 months before being prescribed a biologic or immune response modifier for the first time. CMS requires this because biologics suppress immune function, which can reactivate latent TB in patients who were previously exposed and have no idea.
For MIPS purposes, meeting this measure means demonstrating that your practice has a consistent, documented process for TB screening before initiating biologic therapy. It's not enough that the screening happened. It has to be in the chart.
Quick reference:
- Performance category: Quality
- Minimum case threshold: 20 patients
- TB test window: within the last 12 months prior to prescribing
- Biologic-free window: patient must not have been on any biologic in the last 15 months
Who Qualifies: Understanding Patient Eligibility
This is where practices lose credit they've already earned clinically. The eligibility rules are specific, and misreading them means incomplete data or missed reporting.
The 15-month biologic-free window
For a patient to count toward Measure 176, they cannot have been on any biologic or immune response modifier therapy within the last 15 months. In practice, this means:
- Current biologic patients do not qualify. If a patient has been continuously on Humira, Dupixent, Skyrizi, or any other qualifying biologic, they will not trigger this measure.
- Patients returning to biologics after a gap may qualify. If a patient stopped biologic therapy and has been off it for at least 15 months, they are eligible when you restart treatment.
- "New to your practice" does not mean "new to biologics." If a patient transfers from another office and has been on a biologic within the past 15 months, they do not qualify - regardless of whether you have their previous prescription on file.
The 20-patient minimum
Measure 176 requires at least 20 qualifying cases during the performance year. For practices with high biologic volume, that's an easy bar. For smaller practices, or those with a mostly established biologic patient panel, it's worth estimating how many truly new biologic starts you expect before committing to this measure for the year.
Which biologics qualify?
Not every biologic falls under this measure. CMS and Healthmonix maintain a defined list of qualifying medications tied to specific drug codes. Most standard biologics used in dermatology are on it, but confirm against the current measure specifications before assuming a medication counts.
What Triggers the Measure
Getting clear on what actually triggers Measure 176 prevents one of the most common documentation gaps practices run into.
The trigger is the act of prescribing the biologic - specifically, placing the medication in the prescription queue during an actual clinical encounter.
Two rules follow from this:
1. It must happen during an E&M-coded visit. The measure will not trigger on a virtual encounter, a nurse-only visit, or a phone call. It has to be tied to a real, coded office visit. This trips up practices when a biologics coordinator processes the prescription after reviewing labs remotely - if the prescription is added to the chart through a virtual interaction, it won't count.
2. You do not have to send the prescription to trigger the measure. Queuing the medication in the prescription workflow is enough. This creates a useful workaround: add the biologic to the patient's prescription queue during the office visit, then hold off on sending it until the TB results come back. The measure is triggered. The prescription isn't sent before you have the results. Both your clinical protocol and your MIPS documentation stay intact.
What You Need to Document
Two things must be in the chart for Measure 176 to be reportable:
1. The biologic prescription in the queue
The medication needs to appear in the patient's chart as a prescribed or queued biologic. This is what triggers the measure. If the prescription is called in separately without being entered during the office visit, or processed through a workaround that bypasses the prescription workflow, the trigger may not fire.
2. Evidence of a TB test within the last 12 months
The TB test does not have to be performed in your office. It can be ordered by your practice, sent to an external lab, or completed at another provider's office entirely. What matters is that it's documented in the patient's chart before you prescribe.
Acceptable documentation includes:
- The lab order for QuantiFERON Gold or another approved TB test, visible in the chart
- A treatment plan note on the patient's record indicating TB screening was performed within the last 12 months
- A plain-language chart note confirming the patient received a TB test prior to starting biologic therapy
This comes up a lot: practices with large Eastern European patient populations, or others where BCG vaccination history is common, often use QuantiFERON Gold rather than the PPD skin test because prior BCG vaccination causes false positives. That's clinically appropriate. For MIPS purposes, the method doesn't matter - what matters is that the test was done and documented.
A note on audit risk
MIPS claims are subject to audit. Reviewers will look for documentation that the TB test occurred and that no biologic was prescribed without it. A treatment plan note in the chart - separate from the lab order - gives you a second layer of evidence that your team completed this step deliberately, not by accident.
Common Pitfalls to Avoid
Prescribing through a virtual encounter
If the prescription is added during a telehealth or phone visit rather than an in-person E&M encounter, the measure will not trigger. This catches practices off guard when the biologics coordinator processes the prescription remotely after labs come back.
Not documenting the TB test separately from the prescription
Ordering the lab isn't always enough on its own. If the QuantiFERON Gold order is buried in the chart without a note connecting it to the biologic initiation, auditors may not be able to confirm the sequence. Add a short note or use a treatment plan note that explicitly states the patient received TB screening within the last 12 months before starting the biologic.
Assuming a transfer patient is new to biologics
A patient who transferred from another practice might say they haven't been on biologics "in a while" - but without documentation confirming 15 biologic-free months, you can't assume they qualify. Verify their medication history before counting them toward this measure.
Falling short of the 20-case minimum
If your new biologic starts come in under 20 for the year, you won't qualify for the measure at all - even if every documented case is airtight. Track your biologic initiations early in the performance year so you can assess whether this measure is realistic or whether you need to pivot.
Using a biologic that isn't on the qualifying medication list
The list is specific to drug codes, not just drug names. Confirm which biologics and immune response modifiers fall under this measure's specifications with your Qualified Registry or QCDR.
How Measure 176 Fits Into Your MIPS Strategy
Measure 176 is a strong pick for dermatology practices with active biologic prescribing, particularly those treating psoriasis, atopic dermatitis, or other conditions where biologics are a standard part of the treatment ladder.
It pairs naturally with Measure 410 (Psoriasis: Measurement of Symptoms Addressed During Treatment), which targets an overlapping patient population. If you're already documenting PASI, BSA, or PGA scores for psoriasis patients on biologics, adding Measure 176 creates a logical documentation cluster around the same visits.
For practices in a MIPS Value Pathway (MVP), check whether Measure 176 is part of your selected pathway. Some dermatology-relevant MVPs include biologic-related quality measures as reportable options.
Practices with large biologic panels - 300 or more active patients on ongoing therapy - generally have enough new starts each year to clear the 20-case threshold. If your volume is smaller, estimate your projected new starts before locking in this measure.
One practical note: the end of the performance year has a way of surfacing documentation gaps that built up quietly all year. A simple monthly check - reviewing incomplete cases for this measure - is worth building into your regular workflow so December doesn't become a scramble.
Tracking This at the Practice Level
The responsibility for Measure 176 sits at the intersection of clinical workflow and administrative documentation. The prescriber needs to enter the medication during the visit. The biller or office manager needs to confirm the TB test is in the chart.
A few approaches that help practices stay on track:
- Flag new biologic patients at scheduling. If a patient is coming in to start biologic therapy for the first time (or after a long gap), flag the encounter so staff know to check for TB documentation before the prescription goes out.
- Use a consistent treatment plan note template. A standard note confirming TB screening and biologic initiation - applied the same way every time - makes audits straightforward and catches gaps before they become reporting problems.
- Run measure-specific reports on a regular cadence. Most EHR systems with MIPS tracking surface eligible patients alongside performance and reporting rates. A low performance rate on Measure 176 usually points to missing TB documentation or prescriptions being entered outside of qualifying encounters.
A Note for Ezderm Users
Ezderm tracks Measure 176 through the MACRA Measures wizard - the red "M" indicator that appears at the top of a progress note when eligible patients are seen. The trigger fires when a qualifying biologic is entered into the Rx Bowl during an E&M-coded encounter. Documentation can be added through the treatment plan feature, and tracking is visible through the quality report. Reach out to your Ezderm client specialist if you have questions about how eligible patients are surfacing in your account or how to review incomplete cases.
Tracking TB screening for MIPS doesn't require a new clinical workflow. It requires making sure the workflow your practice already follows leaves the right paper trail. Know who qualifies, trigger the measure during the right type of encounter, and document the TB test where reviewers can find it.
Want to see how Ezderm supports MIPS tracking for dermatology practices? Schedule a demo or explore our MIPS resource guide.
