2024 MIPS Measure #493: Adult Immunization Status

Quality ID 493
NQF 3620
High Priority Measure No
Specifications Registry
Measure Type Process
Specialty Allergy/Immunology Cardiology Endocrinology Family Medicine Geriatrics Infectious Disease Internal Medicine Nephrology Obstetrics/Gynecology Oncology/Hematology Otolaryngology Preventive Medicine Pulmonology Rheumatology Skilled Nursing Facility

Measure Description

Percentage of patients 19 years of age and older who are up-to-date on recommended routine vaccines for influenza; tetanus and diphtheria (Td) or tetanus, diphtheria and acellular pertussis (Tdap); zoster; and pneumococcal.

 

Instructions

This measure is to be submitted a minimum of once per performance period for all patients 19 years of age and older on the date of the encounter. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure for patients age 19 years of age and older based on the services provided and the measure-specific denominator coding.

NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, 95, POS 02, POS 10) are allowable.

This measure will be calculated with 4 performance rates:

1. Percentage of patients (19 years of age and older on the date of the encounter) who received an influenza vaccine on or between July 1 of the year prior to the measurement period and June 30 of the measurement period

2. Percentage of patients (19 years of age and older on the date of the encounter) who received at least 1 tetanus and diphtheria (Td) vaccine or 1 tetanus, diphtheria, and pertussis (Tdap) vaccine between 9 years prior to the encounter and the end of the measurement period

3. Percentage of patients (50 years of age and older on the date of the encounter) who received 2 doses of the herpes zoster recombinant vaccine anytime on or after the patients’ 50th birthday

4. Percentage of patients (66 years of age or older on the date of the encounter) who were administered any pneumococcal conjugate vaccine or polysaccharide vaccine, on or after their 60th birthday and before the end of the measurement period

Submission of the four performance rates is required for this measure. A weighted average, which is the sum of the performance numerator values divided by the sum of performance denominator values, will be used to calculate performance.

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 (Submission Criteria 1)

Patients 19 years of age and older on the date of the encounter with a visit during the measurement period

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 1):

Patients age 19 and older on the date of the encounter

AND

Patient encounter during the performance period (CPT): 90945, 90947, 90957, 90958, 90959, 90960, 90961, 90962, 90965, 90966, 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, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, 99512*, G0438, G0439

AND NOT

DENOMINATOR EXCLUSION:

In hospice or using hospice services during the measurement period (HCPCS): M1167

 

Numerator (Submission Criteria 1)

Patients in Denominator 1 who received an influenza vaccine on or between July 1 of the year prior to the measurement period and June 30 of the measurement period

NUMERATOR NOTE: Patient reported vaccine receipt, when recorded in the medical record, is acceptable for meeting the numerator.

Numerator Options:

Performance Met: Patient received an influenza vaccine on or between July 1 of the year prior to the measurement period and June 30 of the measurement period (M1168)

OR

Denominator Exception: Documentation of medical reason(s) for not administering influenza vaccine (e.g., prior anaphylaxis due to the influenza vaccine) (M1169)

OR

Performance Not Met: Patient did not receive an influenza vaccine on or between July 1 of the year prior to the measurement period and June 30 of the measurement period (M1170)

 

Denominator (Submission Criteria 2)

Patients 19 years of age and older on the date of the encounter with a visit during the measurement period

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 2):

Patients age 19 and older on the date of the encounter

AND

Patient encounter during the performance period (CPT): 90945, 90947, 90957, 90958, 90959, 90960, 90961, 90962, 90965, 90966, 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, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, 99512*, G0438, G0439

AND NOT

DENOMINATOR EXCLUSION:

In hospice or using hospice services during the measurement period (HCPCS): M1167

 

Numerator (Submission Criteria 2)

Patients in Denominator 2 who received at least 1 Td vaccine or 1 Tdap vaccine between 9 years prior to the encounter and the end of the measurement period

NUMERATOR NOTE: Patient reported vaccine receipt, when recorded in the medical record, is acceptable for meeting the numerator.

Numerator Options:

Performance Met: Patient received at least one Td vaccine or one Tdap vaccine between nine years prior to the encounter and the end of the measurement period (M1171)

OR

Denominator Exception: Documentation of medical reason(s) for not administering Td or Tdap vaccine (e.g., prior anaphylaxis due to the Td or Tdap vaccine or history of encephalopathy within seven days after a previous dose of a Td-containing vaccine) (M1172)

OR

Performance Not Met: Patient did not receive at least one Td vaccine or one Tdap vaccine between nine years prior to the encounter and the end of the measurement period (M1173)

 

Denominator (Submission Criteria 3)

Patients 50 years of age and older on the date of the encounter with a visit during the measurement period

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 3):

Patients age 50 and older on the date of the encounter

AND

Patient encounter during the performance period (CPT): 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, 99386*, 99387*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, 99512*, G0438, G0439

AND NOT

DENOMINATOR EXCLUSIONS:

In hospice or using hospice services during the measurement period (HCPCS): M1167

 

Numerator (Submission Criteria 3)

Patients in Denominator 3 who received 2 doses of the herpes zoster recombinant vaccine anytime on or after the patients’ 50th birthday

NUMERATOR NOTE: Patient reported vaccine receipt, when recorded in the medical record, is acceptable for meeting the numerator

Numerator Options:

Performance Met: Patient received at least two doses of the herpes zoster recombinant vaccine (at least 28 days apart) anytime on or after the patient’s 50th birthday before or during the measurement period (M1174)

OR

Denominator Exception: Documentation of medical reason(s) for not administering zoster vaccine (e.g., prior anaphylaxis due to the zoster vaccine) (M1175)

OR

Denominator Exception: Documentation that administration of second recombinant zoster vaccine could not occur during the performance period due to the recommended 2-6 month interval between doses (i.e., first dose received after October 31) (M1238)

OR

Performance Not Met: Patient did not receive two doses of the herpes zoster recombinant vaccine (at least 28 days apart) anytime on or after the patient’s 50th birthday before or during the measurement period (M1176)

 

Denominator (Submission Criteria 4)

Patients 66 years of age or older on the date of the encounter with a visit during the measurement period

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 4):

Patients age 66 and older on the date of the encounter

AND

Patient encounter during the performance period (CPT): 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 EXCLUSION:

In hospice or using hospice services during the measurement period (HCPCS): M1167

 

Numerator (Submission Criteria 4)

Patients in Denominator 4 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 (M1177)

OR

Denominator Exception: Documentation of medical reason(s) for not administering pneumococcal vaccine (e.g., prior anaphylaxis due to the pneumococcal vaccine) (M1178)

OR

Performance Not Met: Patient did not receive any pneumococcal conjugate or polysaccharide vaccine, on or after their 60th birthday and before or during measurement period (M1179)

 

Rational

For adults, the Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination against influenza, tetanus, diphtheria and pertussis for all adults, while vaccines for zoster and pneumococcal disease are recommended for older adults (Murthy, et al. 2022). These vaccines are recommended to prevent serious diseases. Healthy People 2020, which provides science-based, 10-year national objectives for improving the health of all Americans, recommends increasing the percentage of adults who are vaccinated against influenza, zoster and pneumococcal disease (U.S. Department of Health and Human Services [HHS], 2017)

Estimates of national vaccination coverage are available through the National Health Interview Survey (NHIS), in which a sample of adults self-report receipt of vaccines. In 2015, 45 percent of adults 19 and older reported that they received the influenza vaccine during the 2014–2015 flu season, well below the Healthy People 2020 target of 70 percent (Williams et al. 2017). 64 percent of adults 65 and older reported having ever received any pneumococcal vaccine, which is below the Healthy People 2020 target of 90 percent (HHS, 2017). In 2015, 31 percent of adults ages 60 and older reported ever receiving the zoster vaccine (HHS, 2017). Although zoster vaccination coverage meets the Healthy People 2020 target of 30 percent coverage, 70 percent of adults are not receiving this recommended vaccination. Although there is no corresponding Healthy People 2020 goal for routine Td or Tdap vaccination among adults, only 62 percent reported receiving any tetanus toxoid-containing vaccination during the past 10 years (HHS, 2017).

There are evidence-based practices for improving adult vaccination coverage. Health care providers can routinely assess patients’ vaccination history, implement reminder-recall systems, use standing-order programs and analyze practice- or provider-specific vaccination rates (HHS, 2017). In addition, providing easy access and convenience for adult vaccination (such as walk-in visits or extended hours) within and outside of the health care setting is important for increasing adult vaccine uptake (Ventola, 2016). Leveraging health information technology to share immunization data among patients, providers, pharmacies, retail clinics and public health agencies and registries is also a key strategy for tracking patients’ immunization history and keeping them up to date on vaccines (America’s Health Insurance Plans, 2015).

References:

Murthy N, Wodi AP, Bernstein H, McNally V, Cineas S, Ault K. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older — United States, 2022. MMWR Morb Mortal Wkly Rep 2022;71:229–233. DOI: http://dx.doi.org/10.15585/mmwr.mm7107a1

U.S. Department of Health and Human Services. 2017. HealthyPeople.gov 2020 Topics & Objectives: Immunization and Infectious Diseases. (September 25) https://www.healthypeople.gov/2020/topics-objectives/topic/immunizationand-infectious-diseases

Williams W.W., P. Lu, A. O’Halloran, et al. 2017. “Surveillance of Vaccination Coverage among Adult Populations— United States, 2015.” MMWR Surveill Summ. 66(No. SS-11):1–28. DOI: http://dx.doi.org/10.15585/mmwr.ss6611a1

Ventola, C.L. 2016. “Immunization in the United States: Recommendations, Barriers, and Measures to Improve Compliance: Part 2: Adult Vaccinations.” Pharmacy and Therapeutics. 41(8), 492–506.

America’s Health Insurance Plans. 2015. “Stakeholder Roundtable: Improving Adult Immunization Rates.” Retrieved from https://www.ahip.org/documents/Vaccine_Report_8.26.15-1.pdf

 

Clinical Recommendation Statements

The Advisory Committee on Immunization Practices recommends annual influenza vaccination; and tetanus, diphtheria and acellular pertussis (Tdap) and/or tetanus and diphtheria (Td) vaccine; herpes zoster vaccine; and pneumococcal vaccine for adults at various ages.

Reference:

Murthy N, Wodi AP, Bernstein H, McNally V, Cineas S, Ault K. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older — United States, 2022. MMWR Morb Mortal Wkly Rep 2022;71:229–233. DOI: http://dx.doi.org/10.15585/mmwr.mm7107a1.

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