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Pneumococcal Vaccination Status for Older Adults

Measure Information 2023 Performance Period
Title Pneumococcal Vaccination Status for Older Adults
CMS eCQM ID CMS127v11
CBE ID* Not Applicable
MIPS Quality ID 111
Measure Steward National Committee for Quality Assurance
Description

Percentage of patients 66 years of age and older who have received a pneumococcal vaccine
Measure Scoring Proportion measure
Measure Type Process
Stratification *See CMS127v11.html
Risk Adjustment *See CMS127v11.html
Rationale *See CMS127v11.html
Clinical Recommendation Statement *See CMS127v11.html
Improvement Notation

Higher score indicates better quality
Definition *See CMS127v11.html
Guidance

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.
Initial Population

Patients 66 years of age and older at the start of the measurement period with a visit during the measurement period
Denominator

Equals Initial Population
Denominator Exclusions

Exclude patients who are in hospice care for any part of the measurement period
Numerator

Patients who received a pneumococcal vaccination on or after their 60th birthday and before the end of the measurement period
Numerator Exclusions

Not Applicable
Denominator Exceptions

None
Telehealth Eligible Yes
Next Version No Version Available
Previous Version No Version Available
*Verify active CBE endorsement on the CMS certified consensus-based entity’s PQM website
Download XML
Download CSV
Specifications

Only used as part of the MVP reporting and not for traditional MIPS

There is a known issue on CMS127v11. See issue EKI-15 on the ONC eCQM Known Issues Dashboard for details.

Additional Resources for CMS127v11

*Note there may be more tickets for CMS127v11 in the eCQM Tracker - ASTP/ONC Project Tracking System (Jira). Only tickets tagged with their associated CMS measure ID appear.

Use the eCQM Tracker to open new issues regarding eCQM implementation. Log in required.

CMS127v11-TRN.xlsx

Header

  • Revised the measure description to align with the timing intent of when the patient received the vaccination.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated the clinical recommendation statement based on most recent published Advisory Committee on Immunization Practices (ACIP) guidelines.

    Measure Section: Clinical Recommendation Statement

    Source of Change: ONC Project Tracking System (JIRA): CQM-5153

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Removed references to QRDA I guidance to avoid duplicating information provided in the CMS QRDA I Implementation Guide.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.

    Measure Section: Guidance

    Source of Change: Standards/Technical Update

  • Added age anchor specification to the initial population statement to clarify measure requirements.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Removed language related to adverse reactions to align with the measure intent.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Updated grammar and punctuation to improve readability.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Updated the logic to add the 'NormalizeInterval' function to additional QDM datatypes to decrease implementation burden due to variable use of timing attributes.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added QDM datatypes 'Encounter, Performed' and 'Assessment, Performed' and associated logic to the Hospice.'Has Hospice Services' definition to provide additional approaches for identifying patients receiving hospice services.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated the timing precision in the definitions from datetime to date by adding 'day of', 'date from', and/or function 'ToDateInterval' to align with the measure intent.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated the logic to account for the recommended vaccine formulations based on most recent published Advisory Committee on Immunization Practices (ACIP) guidelines.

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (JIRA): CQM-5153

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Updated the logic to remove adverse reaction criteria related to vaccines to align with the intent of the measure.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated the version number of the Hospice Library to v4.0.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical 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.

  • Added direct reference code LOINC code (45755-6) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Removed direct reference code CPT code (90732) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Removed direct reference code SNOMED CT code (293116002) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Removed value set Pneumococcal Polysaccharide 23 Vaccine (2.16.840.1.113883.3.464.1003.110.12.1089) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Discharge Services - Nursing Facility (2.16.840.1.113883.3.464.1003.101.11.1065) with value set Discharge Services Nursing Facility (2.16.840.1.113883.3.464.1003.101.12.1013) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Hospice Encounter (2.16.840.1.113883.3.464.1003.1003) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Adult Pneumococcal Vaccine (2.16.840.1.113883.3.464.1003.1161) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set (2.16.840.1.113883.3.464.1003.101.12.1023): Renamed to Preventive Care Services Initial Office Visit, 18 and Up based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.464.1003.101.12.1025): Renamed to Preventive Care Services Established Office Visit, 18 and Up based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.464.1003.101.12.1014): Renamed to Care Services in Long Term Residential Facility based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced value set Hospice Care Ambulatory (2.16.840.1.113762.1.4.1108.15) with value set Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference code SNOMED CT code (373066001) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Adult Pneumococcal Vaccine Administered (2.16.840.1.113883.3.464.1003.1162) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: May 01, 2025

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