2017 MIPS Measure #394: Immunizations for Adolescents

Measure Description

The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday

Instruction

This measure is to be reported a minimum of once per performance period for patients seen during the performance period. There is no diagnosis associated with this measure. Performance for this measure is not limited to the performance period. This measure may be reported by eligible clinicians who perform the quality actions described inthe measure based on services provided and the measure-specific denominatorcoding

This measure will be calculated with 4 performance rates:

1. Patients who had one dose of meningococcal vaccine on or between the patient’s 11th and 13th birthdays
2. Patients who had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between thepatient’s 10th and 13th birthdays
3. Patients who had at least three HPV vaccines with different dates of service on or between the patient’s 9th and13th birthdays
4. All patients who are compliant for Meningococcal, Tdap and HPV during the specified timeframes.

Denominator

DENOMINATOR (REPORTING CRITERIA FOR ALL RATES):

Adolescents who turn 13 years of age during the measurement period

DENOMINATOR NOTE: The same denominator is used for all rates.

Denominator Criteria (Eligible Cases):
Patients who turn 13 years of age during the measurement period
AND
Patient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337,99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402
AND NOT
DENOMINATOR EXCLUSIONS:
Meningococcal, Tdap and/or HPV vaccine contraindicated OR patient allergic to themeningococcal, Tdap, and/or HPV vaccine
OR
Patients who use hospice services any time during the measurement period: G9761

Numerator

This measure will be calculated with 4 performance rates:
1)Patients who had one dose of meningococcal vaccine on or between the patient’s 11th and 13th birthdays
2)Patients who had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between thepatient’s 10th and 13th birthdays
3)Patients who had at least three HPV vaccines with different dates of service on or between the patient’s 9th and13th birthdays
4)All patients who are compliant for Meningococcal, Tdap and HPV during the specified timeframes.

NUMERATOR (REPORTING CRITERIA 1):
Adolescents who had one dose of meningococcal vaccine on or between the patient’s 11th and 13th birthdays

Numerator Options:
Performance Met: Patient had one dose of meningococcal vaccine on or between the patient’s 11th and 13th birthdays (G9414)
OR
Performance Not Met: Patient did not have one dose ofmeningococcal vaccine on or between the patient’s 11th and 13th birthdays (G9415)

NUMERATOR (REPORTING CRITERIA 2):
Adolescents who had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays

Numerator Options:
Performance Met: Patient had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays (G9416)
OR
Performance Not Met: Patient did not have one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays (G9417)

NUMERATOR (REPORTING CRITERIA 3):
Adolescents who had at least three HPV vaccines on or between the patient’s 9th and 13th birthdays

Numerator Options:
Performance Met: Patient had at least three HPV vaccines on or between the patient’s 9th and 13th birthdays (G9762)
OR
Performance Not Met: Patient did not have at least three HPV vaccines on or between the patient’s 9th and 13th birthdays (G9763)

NUMERATOR (REPORTING CRITERIA 4):
Adolescents who are numerator compliant for Rates 1, 2 and 3