2023 # 110 Preventive Care and Screening: Influenza Immunization

CMS Measure ID: #110

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 for visits for patients seen between January and March for the 2022-2023 influenza season AND a minimum of once for visits for patients seen between October and December for the 2023-2024 influenza season. This measure is intended to determine whether or not all patients aged 6 months and older received (either from the submitting Merit-based Incentive Payment System (MIPS) eligible clinician or from an alternate care provider) the influenza immunization during the flu season. There is no diagnosis associated with this measure. This measure may be submitted by MIPS eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

• If submitting this measure between January 1, 2023 and March 31, 2023, quality data code G8482 should be submitted when the influenza immunization is administered to the patient during the months of August, September, October, November, and December of 2022 or January, February, and March of 2023 for the flu season ending March 31, 2023.
• If submitting this measure between October 1, 2023 and December 31, 2023, quality data code G8482 should be submitted when the influenza immunization is administered to the patient during the months of August, September, October, November, and December of 2023 for the flu season ending March 31, 2024.
• Influenza immunizations administered during the month of August or September of a given flu season (either 2022-2023 flu season OR 2023-2024 flu season) can be submitted when a visit occurs during the flu season (October 1 – March 31). In these cases, G8482 should be submitted

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 submissions; however, these codes may be submitted for those registries that utilize claims data.

Description

Percentage of patients aged 6 months and older seen for a visit during the mesaurement period who received an influenza immunization OR who reported previous receipt of an influenza immunization

2022 Benchmarks (from 2020 CMS data)

Registry

Topped out: No
Capped at 7: No

Minimum: 0 – 34.51
Decile 3: 34.52 – 49.41
Decile 4: 49.42 – 61.9
Decile 5: 61.91 – 73.34
Decile 6: 73.35 – 83.73
Decile 7: 83.74 – 92.56
Decile 8: 92.57 – 98.36
Decile 9: 98.37 – 99.99
Decile 10: 100 – 100

eCQM

Topped out: No
Capped at 7: No

Minimum: 0 – 20.12
Decile 3: 20.13 – 29.03
Decile 4: 29.04 – 36.86
Decile 5: 36.87 – 43.83
Decile 6: 43.84 – 50.67
Decile 7: 50.68 – 57.65
Decile 8: 57.66 – 65.92
Decile 9: 65.93 – 78.07
Decile 10: 78.08 – 100

Denominator

All patients aged 6 months and older seen for a visit during the measurement period

DENOMINATOR NOTE: For the purposes of the program, in order to submit on the flu season 2022-2023, the patient must have a qualifying encounter between January 1 and March 31, 2023. In order to submit on the flu season 2023-2024, the patient must have a qualifying encounter between October 1 and December 31, 2023. A qualifying encounter needs to occur within the flu season that is being submitted; any additional encounter(s) may occur at any time within the measurement period. 

*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 ≥ 6 months 

AND

Patient encounter during January thru March and/or October thru December (CPT or HCPCS): 90945, 90947, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 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, 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, 99512*, G0438, G0439

AND NOT

DENOMINATOR EXCLUSION:
Hospice services provided to patient any time during the measurement period: M1154

Numerator

Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization

Definition:
Previous Receipt – Receipt of the current season’s influenza immunization from another provider OR from same provider prior to the visit to which the measure is applied (typically, prior vaccination would include influenza vaccine given since August 1st).

NUMERATOR NOTE: Denominator Exception(s) are determined at the time of the denominator eligible encounter during the current flu season.

Numerator Instructions:

The numerator for this measure can be met by submitting either administration of an influenza vaccination or that the patient reported previous receipt of the current season’s influenza immunization. If the performance of the numerator is not met, a MIPS eligible clinician can submit a valid denominator exception for having not administered an influenza vaccination. For MIPS eligible clinicians submitting a denominator exception for this measure, there should be a clear rationale and documented reason for not administering an influenza immunization if the patient did not indicate previous receipt, which could include a medical reason (e.g., patient allergy), patient reason (e.g., patient declined), or system reason (e.g., vaccination not available). The system reason should be indicated only for cases of disruption or shortage of influenza vaccination supply.

 

Numerator Options:

Performance Met:

Influenza immunization administered or previously received (G8482)

OR

Denominator Exception:

Influenza immunization was not administered for reasons documented by clinician (e.g., patient allergy or other medical reasons, patient declined or other patient reasons, vaccine not available or other system reasons) (G8483)

OR

Performance Not Met:

Influenza immunization was not administered, reason not given (G8484)


Tags

CQM-2023, CQM-eCQM-2023, CQM-eCQM-MVP-2023, CQM-MVP-2023, ecqm-2023, MVP-2023