CMS 127 - Pneumococcal Vaccination Status for Older Adults

Overview

CMS127v8 (2020)
CMS127v9 (2021)
CMS127v10 (2022)

Identifiers

CMS eCQM ID	NQF eCQM ID	NQF	MIPS Quality ID
CMS127v10	–	–	111

*MIE only supports data collection and reporting using eCQM specifications

Definitions

Description	Percentage of patients 66 years of age and older who have ever received a pneumococcal vaccine
Initial Patient Population	Patients 66 years of age and older 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; or ever had an adverse reaction to the vaccine before the end of the measurement period
Numerator Exclusions	–
Denominator Exceptions	–

Additional Information

Measure Type	Process measure
Measure Scoring	Proportion measure
Granularity	Patient
Improvement Notation	Higher score indicates better quality
Domain	Community/Population Health

Clinical Instructions

New UI Visit Encounter (valid RC202109+)

Original Visit Encounter

Clinical Instructions

Ensure all patients that are 65 years of age or older have received a pneumococcal vaccine or report having received a vaccine. Recording the receipt of the immunization or the administration of the vaccine can be done within or outside of the encounter:

1. Option 1: Record the Receipt of Pneumococcal Vaccination (Historical)
   1. Within Encounter
      1. Open the Immunizations/Injections section of the encounter
      2. Using the Description autocomplete, begin typing the name of the immunization
      3. Add the Date and any Reactions/Comments
      4. Click the Add button
      5. Click the Next button, or close the section
      6. Continue documenting the encounter as needed
      7. When completed, Close and Archive the encounter
   2. Outside Encounter
      1. While in the chart, navigate to MAR/Injections from the Medical Record chart tab
      2. Click the Quick Add link in the upper-right of the page
      3. Record any historical injections
      4. Click the Submit button
2. Option 2: Document the Administration of Pneumococcal Vaccination
   1. Within Encounter
      1. Open the Tests and Procedures section of the encounter
      2. Using the autocomplete, begin typing the name of the vaccination being administered
      3. Click the Add to Exam button
      4. After adding the new section, open the section, fill in all required fields, record the findings, and set to Result.
      5. Click the Next button, or close the section
      6. Continue documenting the encounter as needed
      7. When completed, Close and Archive the encounter
   2. Outside Encounter
      1. While in the chart, navigate to MAR/Injections from the Medical Record chart tab
      2. Click the Add Imm/Inj link in the upper-right of the page
      3. Fill in all required fields
      4. Click the Submit button

Evidence

Initial Patient Population

Name	Value Set
Encounter, Performed: Annual Wellness Visit	2.16.840.1.113883.3.526.3.1240
Encounter, Performed: Home Healthcare Services	2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed: Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.	CPT Code 99211
Encounter, Performed: Office Visit	2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed: Online Assessments	2.16.840.1.113883.3.464.1003.101.12.1089
Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up	2.16.840.1.113883.3.464.1003.101.12.1025
Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up	2.16.840.1.113883.3.464.1003.101.12.1023
Encounter, Performed: Telephone Visits	2.16.840.1.113883.3.464.1003.101.12.1080

Denominator Exclusions

Name	Value Set
Encounter, Performed: Care Services in Long-Term Residential Facility	2.16.840.1.113883.3.464.1003.101.12.1014
Encounter, Performed: Discharge Services - Nursing Facility	2.16.840.1.113883.3.464.1003.101.11.1065
Encounter, Performed: Encounter Inpatient	2.16.840.1.113883.3.666.5.307
Encounter, Performed: Nursing Facility Visit	2.16.840.1.113883.3.464.1003.101.12.1012
Intervention, Order: Hospice care ambulatory	2.16.840.1.113762.1.4.1108.15
Intervention, Performed: Hospice care ambulatory	2.16.840.1.113762.1.4.1108.15

Numerator

Name	Value Set
Diagnosis: Adverse reaction to vaccine product containing Streptococcus pneumoniae antigen (disorder)	SNOMEDCT Code 293116002
Immunization, Administered: Pneumococcal Polysaccharide 23 Vaccine	2.16.840.1.113883.3.464.1003.110.12.1089
rocedure, Performed: Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use	CPT Code 90732

Source(s)

eCQI CMS127