Measure 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.
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
This measure will be calculated with 4 performance rates:
- Patients who had one dose of meningococcal vaccine (serogroups A, C, W, Y), on or between the patient’s 11th 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.
NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, POS 02, POS 10) are allowable. Please note that effective January 1, 2025, while a measure may be denoted as telehealth eligible, specific denominator codes within the encounter may no longer be eligible due to changes outlined in the CY 2024 PFS Final Rule List of Medicare Telehealth Services.
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 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 (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 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 (Submission Criteria 4)
Adolescents who are numerator compliant for Rates 1, 2 and 3
Rationale
Vaccines are a safe and effective way to protect adolescents against potential deadly diseases, including meningococcal meningitis, pertussis (whooping cough) and human papillomavirus. These are serious diseases that can cause breathing difficulties, heart problems, nerve damage, pneumonia, seizures and cancer. Adolescent vaccinations also help protect against disease in populations that lack immunity, such as infants, the elderly and individuals with chronic conditions (National Foundation for Infectious Diseases, 2023). This measure follows the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) guidelines for immunizations (Meites, Kempe, Markowitz, 2016; Liang et al., 2018; Mbaeyi et al., 2020).
References:
National Foundation for Infectious Diseases. AdolescentVaccination.org. 2013. 10 Reasons to be Vaccinated. http://adolescentvaccination.org/10-reasons
Meites, E., A. Kempe, L.E. Markowitz. 2016. “Use of a 2-Dose Schedule for Human Papillomavirus Vaccination— Updated Recommendations of the Advisory Committee on Immunization Practices.” MMWR Morb Mortal Wkly Rep 65:1405–08. DOI: http://dx.doi.org/10.15585/mmwr.mm6549a5.
Liang, J.L., Tiwari, T., Moro, P., Messonnier, N.E., Reingold, A., Sawyer, M., Clark, T.A. 2018. "Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP).” MMWR Recomm Rep 67(2):1-44. https://doi.org/10.15585/mmwr.rr6702a1
Mbaeyi, S.A., Bozio, C.H., Duffy, J., et al. 2020. “Meningococcal Vaccination: Recommendations of the Advisory Committee on Immunization Practices, United States, 2020.” MMWR Recomm Rep69(RR-9): 1-41. http://dx.doi.org/10.15585/mmwr.rr6909a1
Clinical Recommendation Statements
The Advisory Committee on Immunization Practices (ACIP) recommends routine HPV vaccination for adolescents at age 11 or 12 years; vaccination may be given starting at age 9 years. In a two-dose schedule of HPV vaccine, the minimum interval between the first and second doses is 5 months. Persons who initiated vaccination with 9vHPV, 4vHPV or 2vHPV before their 15th birthday and received 2 doses of any HPV vaccine at the recommended dosing schedule (0, 6–12 months), or received three doses of any HPV vaccine at the recommended dosing schedule (0, 1–2, 6 months), are considered adequately vaccinated (Meites, Kempe, and Markowitz 2016).
ACIP recommends a single dose of vaccine be administered at age 11 or 12 years (Liang et al. 2018).
ACIP recommends routine vaccination with a quadrivalent meningococcal conjugate vaccine for adolescents aged 11 or 12 years, with a booster dose at age 16 years (Mbaeyi et al. 2020).
References:
Meites, E., A. Kempe, L.E. Markowitz. 2016. “Use of a 2-Dose Schedule for Human Papillomavirus Vaccination— Updated Recommendations of the Advisory Committee on Immunization Practices.” MMWR Morb Mortal Wkly Rep 65:1405–08. DOI: 10.15585/mmwr.mm6549a5.
Liang, J.L., T. Tiwari, P. Moro, N.E. Messonnier, A. Reingold, M. Sawyer, T.A. Clark. 2018. “Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP).” MMWR Morb Mortal Wkly Rep 67(2):1–44. DOI: 10.15585/mmwr.rr6702a1.
Mbaeyi, S.A., C.H. Bozio, J. Duffy, et al. 2020. “Meningococcal Vaccination: Recommendations of the Advisory Committee on Immunization Practices, United States, 2020.” MMWR Recomm Rep 69(No. RR-9):1–41. DOI: http://dx.doi.org/10.15585/mmwr.rr6909a1.