2026 COLLECTION TYPE:
MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)
MEASURE TYPE:
Process
DESCRIPTION:
The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine (serogroups A, C, W, Y or A, C, W, Y, B), one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the Human Papillomavirus (HPV) vaccine series by their 13th birthday.
INSTRUCTIONS:
Reporting Frequency:
This measure is to be submitted a minimum of once per performance period for denominator eligible cases as defined in the denominator criteria.
Intent and Clinician Applicability:
This measure is intended to reflect the quality of services provided for patients 13 years of age and older who received adolescent immunizations. 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 as defined by the numerator based on the services provided and the measure-specific denominator coding.
Measure Strata and Performance Rates:
This measure contains four strata defined by a single submission criteria. This measure produces four performance rates.
This measure will be calculated with 4 performance rates:
- Patients who had one dose of meningococcal vaccine (serogroups A, C, W, Y or A, C, W, Y, B), on or between the patient’s 10th and 13th birthdays.
- Patients who had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays.
- Patients who have completed the HPV vaccine series with different dates of service on or between the patient’s 9th and 13th birthdays.
- 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.
Implementation Considerations:
For the purposes of MIPS implementation of this measure, this patient-process measure is submitted a minimum of once per patient during the performance period. The most advantageous quality data code (QDC) will be used if the measure is submitted more than once.
Telehealth:
TELEHEALTH ELIGIBLE: This measure is appropriate for and applicable to the telehealth setting. Patient encounters conducted via telehealth using encounter code(s) found in the denominator encounter criteria are allowed for this measure. Therefore, if the patient meets all denominator criteria for a telehealth encounter, it would be appropriate to include them in the denominator eligible patient population. Telehealth eligibility is at the measure level for inclusion within the denominator eligible patient population and based on the measure specification definitions which are independent of changes to coding and/or billing practices.
Measure Submission:
The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this collection type for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. The coding provided to identify the measure criteria: Denominator or Numerator, may be an example of coding that could be used to identify patients that meet the intent of this clinical topic. When implementing this measure, please refer to the ‘Reference Coding’ section to determine if other codes or code languages that meet the intent of the criteria may also be used within the medical record to identify and/or assess patients. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
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): 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 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 (PERFORMANCE RATE 1):
Adolescents who had one dose of meningococcal vaccine (serogroups A, C, W, Y or A, C, W, Y, B), on or between the patient’s 10th and 13th birthdays.
Numerator Options:
Performance Met: Patient had one dose of meningococcal vaccine (serogroups A, C, W, Y or A, C, W, Y, B) on or between the patient’s 10th 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 or A, C, W, Y, B), on or between the patient’s 10th and 13th birthdays (G9415)
NUMERATOR (PERFORMANCE RATE 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 (PERORMANCE RATE 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 (PERFORMANCE RATE 4):
Adolescents who are numerator compliant for Rates 1, 2 and 3.
RATIONALE:
This measure assesses the percentage of adolescents 13 years of age who had one dose of meningococcal vaccine, one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday. The measure calculates a rate for each vaccine and two combination rates. This measure follows the Advisory Committee on Immunization Practices (ACIP) guidelines for immunizations.[1],[2],[3]
These vaccines are available for adolescents to prevent them from acquiring serious diseases and help protect against disease in populations that lack immunity, such as infants, the elderly and individuals with chronic conditions
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