CMS 147 Preventative Care and Screening: Influenza Immunization

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Overview

This measure reports the percentage of patients who received an influenza immunization during the flu season (October 1 through March 31). Only patients who were 6 months old or older at the beginning of the measurement period are counted.

At a Glance

eMeasure ID	CMS147v9
NQF	0041e
Used For?	Medicaid PI/Stage 3, MIPS (Quality)
Domain	Community/Population Health
MIPS Quality ID	110
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 Downloading Measure Specifications and Value Sets for more information. Measure help now 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.

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	All patients aged 6 months and older seen for a visit during the measurement period.
Denominator	Equals Initial Population and seen for a visit between October 1 and March 31.
Numerator:	Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization.

Defining Immunization Period and Flu Season

This measure requires that certain actions take place during specific periods of time:

Flu Season: To qualify for the denominator, patients must have had at least one visit during the Flu Season.

The Flu Season begins 3 months before the start of the measurement period and ends 3 months after the start of the measurement period. When reporting on a measurement period that begins on January 1 and ends on December 31, this means that the Flu Season begins on October 1 of the prior calendar year and ends on March 31 of the current calendar year. For example, if the measurement period ends on December 31, 2020, this measure will report on the Flu Season that began on October 1, 2019 and ended on March 31, 2020.

This measure is used to report on a complete flu season after it ends on the last day of March. If today is November 15, 2020, the measure will be reporting on the flu season that began on October 1, 2019 and ended on March 31, 2020, NOT on the flu season that began October 1, 2020.

Immunization Period: To qualify for the numerator, patients must have received an influenza immunization during the Immunization Period.

The Immunization Period begins 5 months before the start of the measurement period and ends 3 months after the measurement period begins. When reporting on a calendar year that begins on January 1 and ends on December 31, this means that the Immunization Period begins August 1 of the prior calendar year and ends on March 31 of the current year. For example, if today is December 31, 2020, a qualifying influenza immunization must have been given between August 1, 2019 and March 31, 2020.

Initial Patient Population

Patients are counted in the Initial Patient Population if they meet each of the following:

1.

They were 6 months old or older at the beginning of the measurement period. Age is based on the date of birth (DOB) entered on the patient’s Information page.

2.

They met either of the following during the measurement period:

• They had at least one non-voided face-to-face encounter. 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
  • Outpatient Consultation
  • Preventive Care – Established Office Visit, 0 to 17
  • Preventive Care – Initial Office Visit, 0 to 17
  • Preventive Care Services – Established Office Visit, 18 and Up
  • Preventive Care Services – Group Counseling
  • Preventive Care Services – Other
  • Preventive Care Services–Individual Counseling
  • Preventive Care Services–Initial Office Visit, 18 and Up
• They received dialysis. This can be indicated by either of following:
  • An order for dialysis. This is indicated by an order in Orders Tracking History. This order must have a status of Returned or Reviewed. It must be based on a code from one of the following Value Sets: Hemodialysis or Peritoneal Dialysis.
  • A dialysis procedure. This is indicated by a vocabulary term that represents a code from one of the following Value Sets: Hemodialysis or Peritoneal Dialysis. This must be recorded in the Results or in a Flowsheet.

Denominator

Patients who qualified for the IPP will qualify for the denominator if they had either of the following during the Flu Season:

• An encounter. This must be documented in the Plan or E&M section of a Note using a code from the Encounter-Influenza Value Set. Note that the following applies when patients qualified for the IPP using the criteria for a non-voided face-to-face encounter:
  • The encounter that qualifies them for the denominator must occur with the same provider as the encounter that qualified them for the IPP.
  • The encounter that qualifies them for the denominator can occur on the same date as the encounter that qualified them for the IPP as long as it occurs between Jan 1 and March 31 during the measurement period.
• Dialysis. This can be indicated by either of following
  • An order for dialysis. This is indicated by an order in Orders Tracking History. This order must have a status of Returned or Reviewed. It must be based on a code from one of the following Value Sets: Hemodialysis or Peritoneal Dialysis.
  • A dialysis procedure. This is indicated by a vocabulary term that represents a code from one of the following Value Sets: Hemodialysis or Peritoneal Dialysis. This must be recorded in the Results or in a Flowsheet.

Denominator Exclusions

Not Applicable

Numerator

Patients are counted in the numerator if they had an influenza vaccination during the Immunization Period. This can be indicated by any of the following:

• A vocabulary term that represents a code from the Influenza Vaccination Value Sets. This documentation must appear in the Results or in a Flowsheet.
• A vocabulary term that represents a code from the Previous Receipt of Influenza Vaccine Value Sets. This documentation must appear in the Results or in a Flowsheet.
• An order in Orders Tracking History. This order must have a status of Returned or Reviewed. It must be based on a code from the Influenza Vaccination Value Set.
• An indication of Recorded or Administered in Immunizations using a code from the Influenza Vaccine Value Set.

Numerator Exclusions

Not Applicable

Denominator Exception

Patients who met the denominator criteria will be removed from the denominator if they did not meet the numerator criteria and if the influenza vaccine was not given for a reason indicated by one of the following:

• The patient declined the influenza vaccine.
• The influenza vaccine was not given due to a medical, patient, or system reason.
• The influenza vaccine was not given because it was contraindicated, deferred, or refused.
• The patient is allergic to eggs or egg substances.
• The patient is allergic to or intolerant of the influenza vaccine.
• The patient was diagnosed with an allergy/intolerance to the influenza vaccine.

When documenting in Past Medical History (PMHx) or the Problem List, a Date of Onset should be entered using the mm/dd/yyyyy format. For PMHx, 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).

To qualify as a denominator exception, allergies must include a Reaction Date, which represents the first time the allergy was noted. To document the Reaction Date, click the allergy and then click Details. The Allergy Details window is displayed. Enter a date in the Reaction Date field. You can use the Date Picker or enter a date using the MM/DD/YYYY format.

Declined the Influenza Vaccine

Patients who decline the influenza vaccine can qualify for this exception. This must be documented in a Flowsheet or the Results using a code from the Influenza Vaccination Declined Value Set during the immunization period.

Not Given Due to a Medical, Patient, or System Reason

If the influenza vaccine was not given due to a medical, patient, or system reason, the patient can qualify for this exception. This must be documented using a vocabulary term with a parent code from the Influenza Vaccination Value Set and a child code from one of the following Value Sets: Medical Reason, Patient Reason, or System Reason during the immunization period.

Not Given Because Contraindicated, Deferred, or Refused

If the influenza vaccine was not given because it was contraindicated, deferred, or refused, the patient can qualify for this exception. This is indicated by documentation of Not Given in the Immunization Grid using code from the Influenza Vaccine Value Set. This must include a decision of Contraindicated, Deferred, or Refused during the immunization period.

Patient Allergic to Eggs or Egg Substances

If the patient is allergic to eggs or egg substances, they can qualify for this exception. Allergies must be active until end of the Flu Season. Allergies that start after the Flu Season is over will not qualify for the exception. To qualify, allergies must begin no more than 3 months after the start of the measurement period and must not end less than or equal to 3 months after the start of measurement period. Qualifying allergies can be indicated by any of the following:

You must ensure that a SNOMED code from the Allergy to Eggs or Egg Substance Value Sets is linked to the allergen you use for this exception. This must be done in the Code Mapper (Chart > Vocab Admin > Code Mapper). If a SNOMED code from one of these Value Sets is not linked to the term that indicates the allergy, the patient will not be removed from the denominator.

Inactive or resolved allergies must be documented on the Problem List to qualify for this exception. Allergies marked as inactive on the Allergy List on the Facesheet will not qualify a patient for this exception.

• A diagnosis indicating an allergy to eggs. This can be documented as an active, resolved, or inactive diagnosis in Assessment or the Problem List. The diagnosis must be documented with a valid onset date. If resolved, the diagnosis must also have a valid resolved date.
• An allergy documented using an allergen that indicates egg substance can be indicated by either of the following.

• An active allergy documented in the Food section of the Allergy List on the Facesheet. The allergy must be documented with a valid onset date. Note that if the allergy is entered in the Allergy List on the Facesheet, the allergy will remain in the patient's history indefinitely. The only way to end the allergy is to add it through the Problem List.
• An active, resolved, or inactive allergy documented on the Problem List. The allergy must be documented with a valid onset date. If resolved, the allergy must also have a valid resolved date.

If an allergen that represent allergies to egg substances does not exist, you will need to create it.

Allergic To or Intolerant Of the Influenza Vaccine

If the patient is allergic to or intolerant of the influenza vaccine, they can qualify for this exception. Allergies or intolerances must be active until the end of the Flu Season. Allergies or intolerances that start after the Flu Season is over will not qualify for the exception. To qualify, allergies or intolerances must begin no more than 3 months after the start of the measurement period and must not end less than or equal to 3 months after the start of the measurement period.

You must ensure that a SNOMED code from the Influenza Vaccination Value Set is linked to the allergen you use for this exception. If a SNOMED code from the Influenza Vaccination Value Set is not linked to the term that indicates the allergy, the patient will not be removed from the denominator.

An allergy to the influenza vaccine must be documented using a term that indicates an allergy to the influenza vaccine. This can be indicated by either of the following:

• An active allergy to the influenza vaccine documented in the Medications section of the Allergy List on the Facesheet. The allergy must be documented with a valid onset date. Note that if the allergy is entered in the Allergy List on the Facesheet, the allergy will remain in the patient's history indefinitely. The only way to end the allergy is to add it through the Problem List.

• An active, resolved, or inactive allergy to the influenza vaccine documented on the Problem List. The allergy must be documented with a valid onset date. If resolved, the allergy must also have a valid resolved date.

Diagnosed Allergy/Intolerance to the Influenza Vaccine

If the patient was diagnosed with an allergy/intolerance to the influenza vaccine, they can qualify for this exception. This diagnosis must be documented using a code from the Allergy to Influenza Vaccine or Intolerance to Influenza Vaccine Value Set. This documentation can be indicated by either of the following:

• An active diagnosis documented in Past Medical History (PMHx) on the Facesheet. The diagnosis must be documented with a valid onset date. Note that if the diagnosis is entered in Past Medical History (PMHx), the diagnosis will remain in the patient's history indefinitely. The only way to end the diagnosis is to add it through the Problem List and enter a resolved date or inactivate it.
• An active, resolved, or inactivated diagnosis on the Problem List. The diagnosis must be documented with a valid onset date. If resolved, the diagnosis must also have a valid resolved date.