Measure Description
Percentage of patients 66 years of age and older who have ever received a pneumococcal vaccine
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 measurespecific 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.
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
Patients 66 years of age and older with a visit during the measurement period
DENOMINATOR NOTE: This measure assesses whether patients 66 years of age or older have received one or more pneumococcal vaccinations.
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): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, G0438, G0439
AND NOT
DENOMINATOR EXCLUSION:
Patient received hospice services any time during the measurement period: G9707
Numerator
Patients who received a pneumococcal vaccination on or after their 60th birthday and before the end of the measurement period; or had an adverse reaction to the vaccine before the end of the measurement period
NUMERATOR NOTE: The measure provides credit for adults 66 years of age and older who have received the PPSV23 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: Pneumococcal vaccine administered on or after patient’s 60th birthday and before the end of the measurement period (G9991)
OR
Performance Met: Documentation of medical reason(s) for not administering pneumococcal vaccine (e.g., adverse reaction to vaccine) (G9989)
OR
Performance Not Met: Pneumococcal vaccine was not administered on or after patient’s 60th birthday and before the end of the measurement period, reason not otherwise specified (G9990)
Rationale
Pneumococcal disease is a common cause of illness and death in older adults and in persons with certain underlying conditions. The major clinical syndromes of pneumococcal disease include pneumonia, bacteremia and meningitis, with pneumonia being the most common (CDC 2015a). Pneumonia symptoms generally include fever, chills, pleuritic chest pain, cough with sputum, dyspnea, tachypnea, hypoxia tachycardia, malaise and weakness. There are an estimated 400,000 cases of pneumonia in the U.S. each year and a 5%–7% mortality rate, although it may be higher among older adults and adults in nursing homes (CDC 2015b; Janssens and Krause 2004).
Pneumococcal infections result in significant health care costs each year. Geriatric patients with pneumonia require hospitalization in nearly 90 percent of cases, and their average length of stay is twice that of younger adults (Janssens and Krause 2004). Pneumonia in the older adult population is associated with high acute-care costs and an overall impact on total direct medical costs and mortality during and after an acute episode (Thomas et al. 2012). Total medical costs for Medicare beneficiaries during and one year following a hospitalization for pneumonia were found to be $15,682 higher than matched beneficiaries without pneumonia (Thomas et al. 2012). It was estimated that in 2010, the total annual excess cost of hospital-treated pneumonia in the fee-for-service Medicare population was approximately $7 billion (Thomas et al. 2012).
Pneumococcal vaccines have been shown to be highly effective in preventing invasive pneumococcal disease. Studies show that at least one dose of pneumococcal polysaccharide vaccine protects between 50-85 in 100 healthy adults against invasive pneumococcal disease (CDC 2019). When comparing costs, outcomes and quality adjusted life years, immunization with recommended pneumococcal vaccines was found to be more economically efficient than no vaccination, with an incremental cost-effectiveness ratio of $25,841 per quality-adjusted life year gained (Chen et al. 2014).
Clinical Recommendation Statements
The Advisory Committee on Immunization Practices (ACIP) recommends that all adults age 65 years and older receive one dose of the 23-valent pneumococcal polysaccharide vaccine (PPSV23). The 13-valent pneumococcal conjugate vaccine (PCV13) is no longer routinely recommended for all adults age 65 years and older. Instead, shared clinical decision-making for PCV13 use is recommended for persons age 65 years and older who do not have an immunocompromising condition, CSF leak, or cochlear implant and who have not previously received PCV13. When patients and vaccine providers engage in shared clinical decision-making for PCV13 use to determine whether PCV13 is right for the specific individual, considerations may include the individual patient’s risk for exposure to PCV13 serotypes and the risk for pneumococcal disease for that person as a result of underlying medical conditions. If a decision to administer PCV13 is made, it should be administered at least 12 months before PPSV23 (Matanock et al. 2019).