CMS Measure ID: #394
Collection Type: CQM
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
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
NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.
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
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.
2023 Benchmarks (from 2021 CMS data)
Registry
Topped out: No
Capped at 7: No
Decile 0: 0 – 0.97
Decile 1: 0.98 – 4.06
Minimum: 4.07 – 5.97
Decile 3: 5.98 – 11.69
Decile 4: 11.7 – 16.17
Decile 5: 16.18 – 21.38
Decile 6: 21.39 – 25.07
Decile 7: 25.08 – 29.56
Decile 8: 29.57 – 36.68
Decile 9: 36.69 – 45.57
Decile 10: 45.58 – 100
Denominator
DENOMINATOR (SUBMISSION 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, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402
AND NOT
DENOMINATOR EXCLUSION:
Patients who use hospice services any time during the measurement period: G9761
Numerator
NUMERATOR (SUBMISSION 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 (SUBMISSION 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 (SUBMISSION CRITERIA 3):
Adolescents who had at least three HPV vaccines 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 (SUBMISSION CRITERIA 4):
Adolescents who are numerator compliant for Rates 1, 2 and 3