| Measure Information | 2022 Performance Period |
|---|---|
| CMS eCQM ID | CMS147v11 |
| NQF Number | 0041e |
| MIPS Quality ID | 110 |
| Description |
Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization |
| Initial Population |
All patients aged 6 months and older seen for a visit during the measurement period |
| Numerator |
Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization |
| Numerator Exclusions |
Not Applicable |
| Denominator |
Equals Initial Population and seen for a visit between October 1 and March 31 |
| Denominator Exclusions |
None |
| Denominator Exceptions |
Documentation of medical reason(s) for not receiving influenza immunization (e.g., patient allergy, other medical reasons). Documentation of patient reason(s) for not receiving influenza immunization (e.g., patient declined, other patient reasons). Documentation of system reason(s) for not receiving influenza immunization (e.g., vaccine not available, other system reasons). |
| Steward | National Committee for Quality Assurance |
| Measure Scoring | Proportion measure |
| Measure Type | Process measure |
| Improvement Notation |
Higher score indicates better quality |
| Guidance |
The timeframe for the visit during the "Encounter, Performed": "Encounter-Influenza" or "Procedure, Performed": "Peritoneal Dialysis" or "Procedure, Performed": "Hemodialysis" in the Population Criteria-Denominator, refers to the influenza season defined by the measure: October through March (October 1 for the year prior to the start of the reporting period through March 31 during the reporting period). The "Encounter-Influenza" Grouping OID detailed in the data criteria section below is comprised of several individual OIDs of different encounter types. The individual OIDs are included in the value set and should be reviewed to determine that an applicable visit occurred during the timeframe for "Encounter, Performed": "Encounter-Influenza" as specified in the denominator. To enable reporting of this measure at the close of the reporting period, this measure will only assess the influenza season that ends in March of the reporting period. The subsequent influenza season (ending March of the following year) will be measured and reported in the following year. Due to the changing stance of the CDC/ACIP recommendations regarding the live attenuated influenza vaccine (LAIV) for a particular flu season, this measure will not include the administration of this specific formulation of the flu vaccination. Given the variance of the timeframes for the annual update cycles, program implementation, and publication of revised recommendations from the CDC/ACIP, it has been determined that the coding for this measure will specifically exclude this formulation, so as not to inappropriately include this form of the vaccine for flu seasons when CDC/ACIP explicitly advise against it. However, it is recommended that all eligible professionals or eligible clinicians to review the guidelines for each flu season to determine appropriateness of the LAIV and other formulations of the flu vaccine. Should the LAIV be recommended for administration for a particular flu season, eligible professional or clinician may consider one of the following options: 1) satisfy the numerator by reporting either previous receipt or using the CVX 88 for unspecified formulation, 2) report a denominator exception, either as a patient reason (e.g., for patient preference) or a system reason (e.g., the institution only carries LAIV). Patient self-report for procedures as well as immunizations should be recorded in 'Procedure, Performed' template or 'Immunization, Administered' template in QRDA-1. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
| Telehealth Eligible | Yes |
| Next Version | |
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| Measure Information | 2021 Performance Period | 2022 Performance Period | 2023 Performance Period | 2024 Performance Period |
|---|---|---|---|---|
| Title | Preventive Care and Screening: Influenza Immunization | Preventive Care and Screening: Influenza Immunization | Preventive Care and Screening: Influenza Immunization | Preventive Care and Screening: Influenza Immunization |
| CMS eCQM ID | CMS147v10 | CMS147v11 | CMS147v12 | CMS147v13 |
| NQF Number | 0041e | 0041e | 0041e | Not Applicable |
| Description |
Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization |
Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization |
Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization |
Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization |
| Initial Population |
All patients aged 6 months and older seen for a visit during the measurement period |
All patients aged 6 months and older seen for a visit during the measurement period |
All patients aged 6 months and older seen for a visit during the measurement period |
All patients aged 6 months and older seen for a visit during the measurement period |
| Denominator |
Equals Initial Population and seen for a visit between October 1 and March 31 |
Equals Initial Population and seen for a visit between October 1 and March 31 |
Equals Initial Population and seen for a visit between October 1 of the year prior to the measurement period and March 31 of the measurement period |
Equals Initial Population and seen for a visit between October 1 of the year prior to the measurement period and March 31 of the measurement period |
| Denominator Exclusions | None | None | Exclude patients who are in hospice care for any part of the measurement period | Exclude patients who are in hospice care for any part of the measurement period Exclude patients who ever had an anaphylaxis due to the influenza vaccine on or before June 30 of the measurement period |
| Numerator |
Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization |
Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization |
Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization between July 1 of the year prior to the measurement period to June 30 of the measurement period |
Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization between July 1 of the year prior to the measurement period to June 30 of the measurement period |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
Not Applicable |
| Denominator Exceptions |
Documentation of medical reason(s) for not receiving influenza immunization (e.g., patient allergy, other medical reasons). Documentation of patient reason(s) for not receiving influenza immunization (e.g., patient declined, other patient reasons). Documentation of system reason(s) for not receiving influenza immunization (e.g., vaccine not available, other system reasons). |
Documentation of medical reason(s) for not receiving influenza immunization (e.g., patient allergy, other medical reasons). Documentation of patient reason(s) for not receiving influenza immunization (e.g., patient declined, other patient reasons). Documentation of system reason(s) for not receiving influenza immunization (e.g., vaccine not available, other system reasons). |
None |
None |
| Measure Steward | PCPI(R) Foundation (PCPI[R]) | National Committee for Quality Assurance | National Committee for Quality Assurance | National Committee for Quality Assurance |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process measure | Process measure | Process measure | Process measure |
| Improvement Notation |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
| Guidance |
The timeframe for the visit during the "Encounter, Performed": "Encounter-Influenza" or "Procedure, Performed": "Peritoneal Dialysis" or "Procedure, Performed": "Hemodialysis" in the Population Criteria-Denominator, refers to the influenza season defined by the measure: October through March (October 1 for the year prior to the start of the reporting period through March 31 during the reporting period). The "Encounter-Influenza" Grouping OID detailed in the data criteria section below is comprised of several individual OIDs of different encounter types. The individual OIDs are included in the value set and should be reviewed to determine that an applicable visit occurred during the timeframe for "Encounter, Performed": "Encounter-Influenza" as specified in the denominator. To enable reporting of this measure at the close of the reporting period, this measure will only assess the influenza season that ends in March of the reporting period. The subsequent influenza season (ending March of the following year) will be measured and reported in the following year. Due to the changing stance of the CDC/ACIP recommendations regarding the live attenuated influenza vaccine (LAIV) for a particular flu season, this measure will not include the administration of this specific formulation of the flu vaccination. Given the variance of the timeframes for the annual update cycles, program implementation, and publication of revised recommendations from the CDC/ACIP, it has been determined that the coding for this measure will specifically exclude this formulation, so as not to inappropriately include this form of the vaccine for flu seasons when CDC/ACIP explicitly advise against it. However, it is recommended that all eligible professionals or eligible clinicians to review the guidelines for each flu season to determine appropriateness of the LAIV and other formulations of the flu vaccine. Should the LAIV be recommended for administration for a particular flu season, eligible professional or clinician may consider one of the following options: 1) satisfy the numerator by reporting either previous receipt or using the CVX 88 for unspecified formulation, 2) report a denominator exception, either as a patient reason (e.g., for patient preference) or a system reason (e.g., the institution only carries LAIV). This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
The timeframe for the visit during the "Encounter, Performed": "Encounter-Influenza" or "Procedure, Performed": "Peritoneal Dialysis" or "Procedure, Performed": "Hemodialysis" in the Population Criteria-Denominator, refers to the influenza season defined by the measure: October through March (October 1 for the year prior to the start of the reporting period through March 31 during the reporting period). The "Encounter-Influenza" Grouping OID detailed in the data criteria section below is comprised of several individual OIDs of different encounter types. The individual OIDs are included in the value set and should be reviewed to determine that an applicable visit occurred during the timeframe for "Encounter, Performed": "Encounter-Influenza" as specified in the denominator. To enable reporting of this measure at the close of the reporting period, this measure will only assess the influenza season that ends in March of the reporting period. The subsequent influenza season (ending March of the following year) will be measured and reported in the following year. Due to the changing stance of the CDC/ACIP recommendations regarding the live attenuated influenza vaccine (LAIV) for a particular flu season, this measure will not include the administration of this specific formulation of the flu vaccination. Given the variance of the timeframes for the annual update cycles, program implementation, and publication of revised recommendations from the CDC/ACIP, it has been determined that the coding for this measure will specifically exclude this formulation, so as not to inappropriately include this form of the vaccine for flu seasons when CDC/ACIP explicitly advise against it. However, it is recommended that all eligible professionals or eligible clinicians to review the guidelines for each flu season to determine appropriateness of the LAIV and other formulations of the flu vaccine. Should the LAIV be recommended for administration for a particular flu season, eligible professional or clinician may consider one of the following options: 1) satisfy the numerator by reporting either previous receipt or using the CVX 88 for unspecified formulation, 2) report a denominator exception, either as a patient reason (e.g., for patient preference) or a system reason (e.g., the institution only carries LAIV). Patient self-report for procedures as well as immunizations should be recorded in 'Procedure, Performed' template or 'Immunization, Administered' template in QRDA-1. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
To enable reporting of this measure at the close of the measurement period, this measure will only assess the influenza season that starts on October 1 of the year prior to the measurement period and ends on March 31 of the measurement period. The subsequent influenza season (ending March of the following year) will be measured and reported in the following year. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
To enable reporting of this measure at the close of the measurement period, this measure will only assess the influenza season that starts on October 1 of the year prior to the measurement period and ends on March 31 of the measurement period. The subsequent influenza season (ending March of the following year) will be measured and reported in the following year. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| MIPS Quality ID | 110 | 110 | 110 | 110 |
| Telehealth Eligible | Yes | Yes | Yes | Yes |
| Next Version | CMS147v11 | CMS147v12 | CMS147v13 | No Version Available |
| Previous Version | No Version Available |
Data Element Repository
Header
-
Updated the eCQM version number.
Measure Section: eCQM Version Number
Source of Change: Annual Update
-
Updated Measure Steward.
Measure Section: Measure Steward
Source of Change: Measure Lead
-
Updated Measure Developer.
Measure Section: Measure Developer
Source of Change: Measure Lead
-
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
-
Updated disclaimer.
Measure Section: Disclaimer
Source of Change: Annual Update
-
Updated the rationale to align with current evidence.
Measure Section: Rationale
Source of Change: Measure Lead
-
Updated the clinical recommendation statement to align with current clinical recommendations.
Measure Section: Clinical Recommendation Statement
Source of Change: Measure Lead
-
Updated references.
Measure Section: Reference
Source of Change: Measure Lead
-
Added the guidance to clarify the method to report immunization status.
Measure Section: Guidance
Source of Change: Measure Lead
Logic
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Added direct reference code CPT code (99211) as a qualifying encounter based on public feedback and appropriateness to measure.
Measure Section: Initial Population
Source of Change: Annual Update
-
Added online assessments and telephone visits as appropriate encounters based on the increased use of telehealth services.
Measure Section: Initial Population
Source of Change: Measure Lead
-
Deleted the Influenza Vaccine Previously Received definition from the Numerator definition to clarify the correct method to determine immunization status.
Measure Section: Numerator
Source of Change: Measure Lead
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Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.
Measure Section: Multiple Sections
Source of Change: Standards Update
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
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Removed value set Previous Receipt of Influenza Vaccine (2.16.840.1.113883.3.526.3.1185) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
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Value set Influenza Vaccine (2.16.840.1.113883.3.526.3.1254): Added 2 CVX codes (205, 149) based on terminology update and based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations.
Measure Section: Terminology
Source of Change: Measure Lead
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Added value set Online Assessment (2.16.840.1.113883.3.464.1003.101.12.1089) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
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Added value set Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
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Added direct reference code CPT code (99211) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead