Pneumococcal Vaccination Status for Older Adults
Compare Versions of: "Pneumococcal Vaccination Status for Older Adults"
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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 | 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 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 | |
| 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 |
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
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