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, 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.
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 19th 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, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 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, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 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, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 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, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 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 19th 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 19th 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 19th 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 19th birthday and before or during measurement period (M1179)
Rationale
The Advisory Committee on Immunization Practices (ACIP) recommends influenza and Td/Tdap vaccination for all adults 19 years of age and older; herpes zoster vaccination for all adults 50 years and older; and pneumococcal vaccination for all adults 65 and older and for those 18–64 with certain underlying conditions (Murthy, et al. 2023). These vaccines are recommended to prevent serious diseases, but vaccination coverage remains low, leaving many adults unprotected against vaccine-preventable diseases (Lu et a., 2021).
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 Data from 2021 indicate that: 50.3% of adults 19 and older reported receiving the influenza vaccine during the 2020-2021 flu season; 41.1% of adults ages 60 and older and 32.6% of adults 50 and older reported receiving the herpes zoster vaccine; and 65.8% of adults 65 and older reported receiving one or more doses of any type of pneumococcal vaccine was 65.8% (Hung et al., 2023). Additionally, NHIS data from 2019 found that 62.9% of adults reported having received any tetanus toxoidcontaining vaccination during the past 10 years and 30.1% reported receiving the Tdap vaccine in the past 10 years (Jatlaoui et al., 2022).
There are evidence-based practices for improving adult vaccination coverage. Health care providers can routinely assess patients’ vaccination history and offer needed vaccines to adults, implement reminder-recall systems, use standing-order programs and analyze practice- or provider-specific vaccination rates (Williams et al., 2017). In addition, providing easy access and convenience for adult vaccination (such as walk-in visits, extended hours, or offering vaccines at retail clinics) 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. 2023. “Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older — United States, 2023.” MMWR Morb Mortal Wkly Rep 2023;72:141-133. DOI: http://dx.doi.org/10.15585/mmwr.mm7206a2
Lu, P., M. Hung, A. Srivastav, et al. 2021. “Surveillance of Vaccination Coverage among Adult Populations—United States, 2018.” MMWR Surveill Summ 2021. 70(No. SS-3):1–26. DOI: http://dx.doi.org/10.15585/mmwr.ss7003a1
Hung, M.C., et al. 2023. “Vaccination Coverage among Adults in the United States, National Health Interview Survey, 2021.” Last updated July 19. https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/pubsresources/vaccination-coverage-adults-2021.html#:~:text=40.2%25)%20adults.- ,Among%20adults%20aged%2019%E2%80%9349%20years%2C%20White%20adults%20had%20higher,than%20 Asian%20(47.0%25)
Jatlaoui T., Hung, M. et al. 2022 “Vaccination Coverage among Adults in the United States, National Health Interview Survey, 2019-2020.” Last Updated February 17, 2022. https://www.cdc.gov/vaccines/imzmanagers/coverage/adultvaxview/pubs-resources/vaccination-coverage-adults-2019-2020.html
Williams, W.W., Lu, P., O’Halloran, A. et al. 2017. “Surveillance of Vaccination Coverage among Adult Populations—United States, 2015.” MMWR Surveill Summ 2017. 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, 2023. MMWR Morb Mortal Wkly Rep 2023;72:141-133. DOI: http://dx.doi.org/10.15585/mmwr.mm7206a2.