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Pneumococcal Vaccination Status for Older Adults

Measure Information 2023 Performance Period
CMS eCQM ID CMS127v11
NQF Number Not Applicable
Description

Percentage of patients 66 years of age and older who have received a pneumococcal vaccine

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

Measure Steward National Committee for Quality Assurance
Quality Domain Community/Population Health
Measure Scoring Proportion measure
Measure Type Process measure
Improvement Notation

Higher score indicates better quality

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.

MIPS Quality ID 111
Meaningful Measure Preventive Care
Telehealth Eligible Yes
Next Version No Version Available
Previous Version

Compare eCQM Versions

The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.

Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.

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Measure Information 2021 Performance Period 2022 Performance Period 2023 Performance Period
Title Pneumococcal Vaccination Status for Older Adults Pneumococcal Vaccination Status for Older Adults Pneumococcal Vaccination Status for Older Adults
CMS eCQM ID CMS127v9 CMS127v10 CMS127v11
NQF Number Not Applicable Not Applicable Not Applicable
Description

Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine

Percentage of patients 66 years of age and older who have ever received a pneumococcal vaccine

Percentage of patients 66 years of age and older who have received a pneumococcal vaccine

Initial Population

Patients 65 years of age and older with a visit during the measurement period

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

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

Equals Initial Population

Equals Initial Population

Denominator Exclusions Exclude patients whose hospice care overlaps the measurement period 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
Numerator

Patients who have ever received a pneumococcal vaccination before the end of the measurement period

Patients who received a pneumococcal vaccination on or after their 60th birthday and before the end of the measurement period; or ever had an adverse reaction to the vaccine before the end of the measurement period

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

Numerator Exclusions

Not Applicable

Not Applicable

Not Applicable

Denominator Exceptions

None

None

None

Measure Steward National Committee for Quality Assurance National Committee for Quality Assurance National Committee for Quality Assurance
Quality Domain Community/Population Health Community/Population Health Community/Population Health
Measure Scoring Proportion measure Proportion measure Proportion measure
Measure Type Process measure Process measure Process measure
Improvement Notation

Higher score indicates better quality

Higher score indicates better quality

Higher score indicates better quality

Guidance

Patient self-report for procedures as well as immunization s should be recorded in 'Procedure, Performed' template or 'Immunization, Administered' template in QRDA-1.

ACIP (Kobayashi, 2015) provides guidance about the proper interval and relative timing for the administration of two pneumococcal vaccines; this measure assesses whether patients have received at least one of either vaccine.

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.

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 (https://ecqi.healthit.gov/qdm) for more information on the QDM.

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 111 111 111
Meaningful Measure Preventive Care Preventive Care Preventive Care
Telehealth Eligible Yes Yes Yes
Next Version CMS127v10 CMS127v11 No Version Available
Previous Version No Version Available

Release Notes

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: Aug 29, 2022