2023 # 111 Pneumococcal Vaccination Status for Older Adults

*This measure can only be reported through an MVP*
CMS Measure ID: #111

Collection Type: 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

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: No
Capped at 7: No

Decile 0: 0 – 0.79
Decile 1: 0.8 – 31.23
Minimum: 31.24 – 51.61
Decile 3: 51.62 – 62.81
Decile 4: 62.82 – 69.62
Decile 5: 69.63 – 74.69
Decile 6: 74.7 – 79.22
Decile 7: 79.23 – 83.7
Decile 8: 83.71 – 89.61
Decile 9: 89.62 – 98.22
Decile 10: 98.23 – 100

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 Immunocompromising Conditions”:

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

Patient received hospice services any time during the measurement period: G9707

Patient received active chemotherapy any time during the measurement period: M1156

Patient received bone marrow transplant any time during the measurement period: M1157

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)

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)