CMS Measure ID: #111
Collection Type: CQM, eCQM, MVP
Reporting Frequency: Once per patient per year
Outcome: No
High Priority: No
NQS Domain: Community, Population and Public Health
Measure Age: > 2 years
Instructions
This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. There is no diagnosis associated with this measure. Performance for this measure is not limited to the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on services provided and the measure-specific denominator coding.
NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable. This measure specification is only available for MIPS Value Pathways (MVP) reporting and is not available for traditional MIPS reporting.
Measure Submission Type:
The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.
Description
Percentage of patients 66 years of age and older who have received a pneumococcal vaccine
2022 Benchmarks (from 2020 CMS data)
Registry
Topped out: No
Capped at 7: No
Minimum: 0 – 41.6
Decile 3: 41.61 – 54.67
Decile 4: 54.68 – 63.59
Decile 5: 63.6 – 69.76
Decile 6: 69.77 – 74.56
Decile 7: 74.57 – 79.44
Decile 8: 79.45 – 85.74
Decile 10: 96.44 – 100
Decile 9: 85.75 – 96.43
eCQM
Topped out: No
Capped at 7: No
Minimum: 0 – 22.13
Decile 3: 22.14 – 36.49
Decile 4: 36.5 – 48.08
Decile 5: 48.09 – 57.67
Decile 6: 57.68 – 65.43
Decile 7: 65.44 – 72.87
Decile 8: 72.88 – 80.23
Decile 10: 88.36 – 100
Decile 9: 80.24 – 88.35
Denominator
Patients 66 years of age and older with a visit during the measurement period
Definitions:
Active Chemotherapy during the Measurement Period (Denominator Exclusion) — The following codes would be sufficient to define the Denominator Exclusion of “Active Chemotherapy”:
- Chemotherapy Encounter (ICD-10-CM): Z51 .0, Z51 .11, Z51 .12
- Chemotherapy Procedure (CPT or HCPCS): 96401, 96402, 96405, 96406, 96409, 96413, 96416, 96420, 96422, 96425, 96440, 96450, 96521, 96522, 96523, 96542, 96549
Bone Marrow Transplant during the Measurement Period (Denominator Exclusion) —The following codes would be sufficient to define the Denominator Exclusion of “Bone Marrow Transplant” (ICD-10-PCS): 30233AZ, 30233G0, 30233G2, 30233G3, 30233G4, 30233X0, 30233X2, 30233X3, 30233X4, 30233Y0, 30233Y2, 30233Y3, 30233Y4, 30243AZ, 30243G0, 30243G2, 30243G3, 30243G4, 30243X0, 30243X2, 30243X3, 30243X4, 30243Y0, 30243Y2, 30243Y3, 30243Y4
History of Immunocompromising Conditions, Cochlear Implants, Anatomic or Functional Asplenia, Sickle Cell Anemia & HB-S Disease or Cerebrospinal Fluid Leaks Any Time during the Patient’s History prior to or during the Measurement Period (Denominator Exclusion) –The following codes would be sufficient to define the Denominator Exclusion of “History of ImmunocompromisingConditions”:
- Anatomic or Functional Asplenia (ICD-10-CM): Q89.01
- Cerebrospinal Fluid Leak (ICD-10-CM): G96.0, G96.00, G96.01, G96.02, G96.08, G96.09, G97.0
- Cochlear Implant (CPT): 69930
- Cochlear Implant Device (HCPCS): L8614, L8619, L8627, L8628
- Cochlear Implant Diagnosis (ICD-10-CM): Z96.20, Z96.21
- Immunocompromising Conditions (ICD-10-CM): B20, B59, B97.35, C80.2, C88.8, C94.40, C94.41, C94.42, C94.6, D46.22, D47.1, D47.9, D47.Z1, D47.Z9, D61.09, D61.810, D61.811, D61.818, D70.0, D70.1, D70.2, D70.4, D70.8, D70.9, D71, D72.0, D72.810, D72.818, D72.819, D73.81, D75.81, D76.1, D76.2, D76.3, D80.0, D80.1, D80.2, D80.3, D80.4, D80.5, D80.6, D80.7, D80.8, D80.9, D81.0, D81.1, D81.2, D81.4, D81.6, D81.7, D81.89, D81.9, D82.0, D82.1, D82.2, D82.3, D82.4, D82.8, D82.9, D83.0, D83.1, D83.2, D83.8, D83.9, D84.0, D84.1, D84.8, D84.81, D84.821, D84.822, D84.89, D84.9, D89.3, D89.810, D89.811, D89.812, D89.813, D89.82, D89.89, D89.9, E40, E41, E42, E43, I12.0, I13.11, I13.2, K91.2, M35.9, N18.5, N18.6, T86.00, T86.01, T86.02, T86.03, T86.09, T86.10, T86.11, T86.12, T86.13, T86.19, T86.20, T86.21, T86.22, T86.23, T86.290, T86.298, T86.30, T86.31, T86.32, T86.33, T86.39, T86.40, T86.41, T86.42, T86.43, T86.49, T86.5, T86.810, T86.811, T86.812, T86.818, T86.819, T86.830, T86.831, T86.832, T86.838, T86.839, T86.850, T86.851, T86.852, T86.858, T86.859, T86.890, T86.891, T86.892, T86.898, T86.899, T86.90, T86.91, T86.92, T86.93, T86.99, Z21, Z48.21, Z48.22, Z48.23, Z48.24, Z48.280, Z48.290, Z48.298, Z49.01, Z49.02, Z49.31, Z94.0, Z94.1, Z94.2, Z94.3, Z94.4, Z94.81, Z94.82, Z94.83, Z94.84, Z94.89, Z99.2
- Sickle Cell Anemia and HB-S Disease (ICD-10-CM): D57.00, D57.01, D57.02, D57.1, D57.20, D57.211, D57.212, D57.219, D57.40, D57.411, D57.412, D57.419, D57.80, D57.811, D57.812, D57.819
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 66 years on date of encounter
AND
Patient encounter during the performance period (CPT or HCPCS): 90945, 90947, 90960, 90961, 90962, 90966, 90970, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99387*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, 99512*, G0438, G0439
AND NOT
DENOMINATOR EXCLUSIONS:
Patient had anaphylaxis due to the pneumococcal vaccine any time during or before the measurement period: M1155
OR
Patient received hospice services any time during the measurement period: G9707
OR
Patient received active chemotherapy any time during the measurement period: M1156
OR
Patient received bone marrow transplant any time during the measurement period: M1157
OR
Patient had history of immunocompromising conditions prior to or during the measurement period: M1158
Numerator
Patients who were administered any pneumococcal conjugate vaccine or polysaccharide vaccine on or after their 60th birthday and before the end of the measurement period
NUMERATOR NOTE: The measure provides credit for adults 66 years of age and older who have received any pneumococcal vaccine on or after the patient’s 60th birthday.
Patient reported vaccine receipt, when recorded in the medical record, is acceptable for meeting the numerator.
Numerator Options:
Performance Met:
Patient received any pneumococcal conjugate or polysaccharide vaccine on or after their 60th birthday and before the end of the measurement period (G9991)
OR
Performance Not Met:
Patient did not receive any pneumococcal conjugate or polysaccharide vaccine on or after their 60th birthday and before the end of the measurement period (G9990)