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
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
Telehealth Eligible	Yes
Next Version	No Version Available
Previous Version	CMS127v10

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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
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 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
Telehealth Eligible	Yes	Yes	Yes
Next Version	CMS127v10	CMS127v11	No Version Available
Previous Version	No Version Available	CMS127v9	CMS127v10

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Specifications

Attachment	Size
CMS127v11.html	65.12 KB
CMS127v11.zip	73.59 KB
CMS127v11-TRN.xlsx	22.22 KB

*Note: There is a known issue on CMS127v11. See issue EKI-15 on the ONC eCQM

Data Element Repository

Data Elements contained within CMS127v11

Value Sets

Value Sets to be used with CMS127v11

Release Notes

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