2024 MIPS Measure #394: Immunizations for Adolescents

2024 COLLECTION TYPE:

MIPS Clinical Quality Measures (CQMS)

‌MEASURE TYPE: Process

Description

‌The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine (serogroups A, C, W, Y), one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the Human Papillomavirus (HPV) vaccine series by their 13th birthday.

‌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.

This measure will be calculated with 4 performance rates:

1. Patients who had one dose of meningococcal vaccine (serogroups A, C, W, Y), on or between the patient’s 11th and 13th birthdays
2. Patients who had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays
3. Patients who have completed the HPV vaccine series with different dates of service on or between the patient’s 9th and 13th birthdays
4. All patients who are compliant for Meningococcal (serogroups A, C, W, Y), Tdap and HPV during the specified timeframes

For accountability reporting in the CMS MIPS program, the rate for Submission Criteria 4 is used for performance.

NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, 95, POS 02, POS 10) are allowable.

‌Measure Submission Type

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. 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 by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

‌Denominator (Submissions Criteria For All Rates)

Adolescents who turn 13 years of age during the measurement period

DENOMINATOR NOTE: The same denominator is used for all rates.

Denominator Criteria (Eligible Cases):

Patients who turn 13 years of age during the measurement period

AND

Patient encounter during the performance period (CPT or HCPCS): 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, G0402

AND NOT

Denominator Exclusion:

Patients who use hospice services any time during the measurement period: G9761

‌Numerator (Submissions Criteria 1):

Adolescents who had one dose of meningococcal vaccine (serogroups A, C, W, Y), on or between the patient’s 11th and 13th birthdays

Numerator Options:

Performance Met: Patient had one dose of meningococcal vaccine (serogroups A, C, W, Y) on or between the patient’s 11th and 13th birthdays (G9414)

OR

Denominator Exception: Patient had anaphylaxis due to the meningococcal vaccine any time on or before the patient’s 13th birthday (M1160)

OR

‌Performance Not Met: Patient did not have one dose of meningococcal vaccine (serogroups A, C, W, Y), on or between the patient’s 11th and 13th birthdays (G9415)

Numerator (Submissions Criteria 2):

Adolescents who had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays

Numerator Options:

Performance Met: Patient had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays (G9416)

OR

Denominator Exception: Patient had anaphylaxis due to the tetanus, diphtheria or pertussis vaccine any time on or before the patient’s 13th birthday (M1161)

OR

Denominator Exception: Patient had encephalitis due to the tetanus, diphtheria or pertussis vaccine any time on or before the patient’s 13th birthday (M1162)

OR

‌Performance Not Met: Patient did not have one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays (G9417)

Numerator (Submissions Criteria 3):

Adolescents who completed the HPV vaccine series on or between the patient’s 9th and 13th birthdays

Numerator Options:

Performance Met: Patient had at least two HPV vaccines (with at least 146 days between the two) OR three HPV vaccines on or between the patient’s 9th and 13th birthdays (G9762)

OR

Denominator Exception: Patient had anaphylaxis due to the HPV vaccine any time on or before the patient’s 13th birthday (M1163)

OR

Performance Not Met: Patient did not have at least two HPV vaccines (with at least 146 days between the two) OR three HPV vaccines on or between the patient’s 9th and 13th birthdays (G9763)

Numerator (Submissions Criteria 4):

‌Adolescents who are numerator compliant for Rates 1, 2 and 3