• Measure 111 (NQF 0043): Pneumonia Vaccination Status for Older Adults


    Updated January 2018.

    Reporting Options: 

    • IRIS Registry EHR: group and individual
    • IRIS Registry manual data entry: group and individual
    • EHR through your vendor (if offered): group and individual
    • Claims-based reporting: Individual only

    Measure Type:  Process

    Description:  This measure is to be submitted a minimum of once per performance period for patients, aged 65 years and older, who have ever received a pneumococcal vaccine.

    To Which Patients Does the Measure Apply?

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

    There are two criteria for inclusion of a patient into the denominator.

    1. Patient characteristics: Description located in “Instructions” (see above).
    2. Procedure codes (CPT or HCPCS): Codes located in “CPT Codes” and “HCPCS Code.”

    The quality measure also has exclusions for the denominator.

    Diagnosis Codes

    This measure does not require a specific diagnosis to be submitted during the encounter.

    CPT Codes

    99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439

    Denominator note: This measure assesses whether patients 65 years of age or older have received one or more pneumococcal vaccinations.

    How to Report the Measure

    Claims and IRIS Registry Manual Reporting

    Category II Codes

    Numerator: Patients who have ever received a pneumococcal vaccination

    Numerator note: While the measure provides credit for adults 65 years of age and older who have ever received either the PCV13 or PPSV23 vaccine (or both), according to ACIP recommendations, patients should receive both vaccines. The order and timing of the vaccinations depends on certain patient characteristics, and are described in more detail in the ACIP recommendations.

    • Exclusion (patient not eligible): G9707 Patient received hospice services any time during the measurement period 
    • Performance met (patient included in numerator and denominator): 4040F Pneumococcal vaccine administered or previously received
    • Performance not met (patient not included in numerator, but included in denominator): 4040F 8P Pneumococcal vaccine was not administered or previously received, reason not otherwise specified

    IRIS Registry EHR Reporting

    Instructions: Percentage of patients aged 65 years and older who have ever received a pneumococcal vaccine. Your EHR and the IRIS Registry will identify all eligible patients and encounters for the denominator.

    Required Documentation in EHR: These are the required elements to be documented at least once a year to meet the measure performance requirements.

    • Reporting history of the patient receiving a pneumococcal vaccine OR administration of pneumococcal vaccine.

    Clinical Recommendation Statements: In 2014, the Advisory Committee on Immunization Practices (ACIP) began recommending a dose of 13-valent pneumococcal conjugate vaccine (PCV13) be followed by a dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) 6-12 months later in adults aged 65 and older who have not previously received a pneumococcal vaccination, and in persons over the age of two years who are considered to be at higher risk for pneumococcal disease due to an underlying condition. The two vaccines should not be coadministered and intervals for administration of the two vaccines vary slightly depending on the age, risk group, and history of vaccination (Kobayashi, 2015).

    In 2015, ACIP updated its recommendation and changed the interval between PCV13 and PPSV23, from 6-12 months to at least one year for immunocompetent adults aged >=65 years who have not previously received pneumococcal vaccine. For immunocompromised vaccine-naïve adults, the minimum acceptable interval between PCV13 and PPSV23 is 8 weeks. Both immunocompetent and immunocompromised adults aged >=65 years who have previously received a dose of PPSV23 when over the age of 65 should receive a dose of PCV13 at least one year after PPSV23 (>=1 year). Immunocompetent and immunocompromised adults aged >=65 who have previously received a dose of PPSV23 when under the age of 65, should also receive a dose of PCV13 at least one year after PPSV23 (>=1 year) and then another dose of PPSV23 at least one year after PCV13. It is recommended that for those that have this alternative three-dose schedule (2 PPSV23 and 1 PCV13), the three doses should be spread over a time period of five or more years (Kobayashi, 2015).

    How CMS Scores Your Performance

    • If you successfully report a measure for less than 60 percent of your patients, you will earn points based on your practice size:
      • Small practices (≤ 15 clinicians) will receive 3 points,
      • Larger practices (> 15 clinicians) will receive 1 point.
    • If you successfully report a measure for at least 60 percent of your patients, but do not report at least 20 cases, you will receive 3 points.
    • If you report this measure for at least 60 percent of applicable patients and on at least 20 patients during a reporting period, you will earn points based on the decile that corresponds to your performance rate. Not all measures offer points for every decile.
    Decile/Points EHR (including EHR- IRIS integration) Registry (No EHR) Claims
    3 15.40 – 25.61 29.93 – 45.27 44.78 – 55.87
    4 25.62 – 37.30 45.28 – 55.09 55.88 – 65.57
    5 37.31 – 47.48 55.10 – 62.58 65.58 – 73.27
    6 47.49 – 56.46 62.59 – 69.99 73.28 – 80.67
    7 56.47 – 65.52 70.00 – 76.96 80.68 – 87.34
    8 65.53 – 75.08 76.97 – 83.99 87.35 – 93.84
    9 75.0 – 85.70 84.00 – 92.88 93.85 – 99.68
    10 >=85.71 >92.89 >=99.69