CMS 127 Pneumococcal Vaccination Status for Older Adults
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Click the following dropdown to see what's new for this measure in 2020.
What's New in 2020
The CMS 127 Pneumococcal Vaccination Status for Older Adults measure has been updated for 2020 reporting in PSR v2020.3. Here's a summary of what's changed since the 2019 reporting logic was released in PSR 2019.
All CMS measures in PSR v2020.3 use logic described in the following help topic: Identifying Event Times. Some of this logic was revised for version PSR 2020.2.
Measure Specification and Value Sets Changes
For the 2020 reporting year, the detailed measure help for this measure includes hyperlinks to the Value Sets used by this measure. You must be registered for a UMLS license and signed in to your account to see this content.
Overview
This measure reports the percentage of patients 65 years old or older who received a pneumococcal vaccine from the practice at any point in time.
At a Glance
| eMeasure ID | CMS127v8 |
| NQF | N/A |
| Used For? | Medicaid PI/Stage 3, MIPS (Quality) |
| Domain | Community/Population Health |
| MIPS Quality ID | 111 |
| MIPS Measure Type | Process |
| MIPS High Priority? | No |
Measure Specification and Value Sets
You should be familiar with this measure’s specification, Value Sets, and direct reference codes (if applicable). Refer to
Identifying Event Times
See Identifying Event Times for important information about the logic this dashboard uses.
Amending Signed Notes
As a best practice, Notes should not be signed until they are finalized. Amending a signed Note (by making changes to it in Prime Suite and then re-saving it) will change a patient’s qualification for this measure. Re-signing the amended Note may allow the patient to qualify again, but only if it is re-signed during the time period required by the measure.
Measure Calculations
| Initial Population | Patients 65 years of age or older with a visit during the measurement period. |
| Denominator | Initial Patient Population |
| Numerator | Patients who have ever received a pneumococcal vaccination before the end of the measurement period. |
Measure Details
Initial Population/Denominator
Patients are counted in the denominator if they meet both of the following:
| 1. | They were 65 years old or older at the beginning of the measurement period. Age is based on the date of birth (DOB) entered on the Information page. |
| 2. | They had at least one non-voided face-to-face encounter during the measurement period. This must be documented in the Plan or E&M section of a Note using a code from one of the following Value Sets: |
- Annual Wellness Visit
- Care Services in Long-Term Residential Facility
- Discharge Services – Nursing Facility
- Home Healthcare Services
- Nursing Facility Visit
- Office Visit
- Preventive Care Services – Established Office Visit, 18 and Up
- Preventive Care Services – Initial Office Visit, 18 and Up
Denominator Exclusions
Patients who received hospice care will be excluded from the denominator. This can be indicated by any of the following:
- They were discharged from the hospital into hospice care during the measurement period. This must be documented with a vocabulary term using a parent code from the Encounter Inpatient Value Set and a child code using either of the following SNOMEDCT version 2019-05-10 direct reference codes:
- 428371000124100 indicating a patient was Discharged to a health care facility for hospice care.
- 428361000124107 indicating a patient was Discharged to home for hospice care.
- They received hospice care. This must be documented with a vocabulary term in a Flowsheet using a code from the Hospice care ambulatory Value Set. The date the provider enters this documentation must occur during the measurement period.
- They had an order for hospice care. This must be documented in the Plan or Results section of a Note using a code from the Hospice care ambulatory Value Set. This order must have been created during the measurement period.
Numerator
Patients are counted in the numerator if they received a pneumococcal vaccination at any point in time prior to the measurement period end date. This can be documented in any of the following:
- Orders Tracking History (with status of Returned or Reviewed), using a code from the Pneumococcal Vaccine Administered Value Set.
- Immunizations, using a code from the Pneumococcal Vaccine Value Set.
- A vocabulary term in the Results or in a Flowsheet, using a code from the Pneumococcal Vaccine Administered Value Set.
- Past Medical History, using a code from the Pneumococcal Vaccine Administered Value Set.
When documenting in Past Medical History (PMHx), a Date of Onset should be entered using the mm/dd/yyyyy format. Use Code Mapper to ensure that the term you’re using has been mapped to a code from the correct Value Set (Chart > Vocab Admin > Code Mapper > PMHx).
Numerator Exclusions
None
Denominator Exception
None
