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Measure 111


Pneumococcal Vaccination Status for Older Adults

Description: The percentage of patients 65 years of age or older who have ever received a pneumococcal vaccine.  

Measure ID: 111 

Type: Process

CMS Derm Specialty Set: No

Priority: No

Topped out: No

Reporting methods: Registry/QCDR, EHR, or Claims

Maximum points: 10

Measure purpose: This measure encourages pneumococcal vaccination among patients who are 65 years or older, who often suffer illness or death in association with pneumonia.

Calculation

The numerator: The number of patients aged 65 or older who receive a pneumococcal vaccination during a visit or who report that they have already received a pneumococcal vaccination

÷

The denominator: All patients 65 years of age or older with a visit during the reporting period.

Measure calculation example
Dr. Petrov saw 115 patients who are 65 years of age or older during the reporting period. This is the denominator.

Three patients are excluded from the denominator because they received hospice service during the measurement period.

Of these patients, 69 received a pneumococcal vaccination or reported that they have already received a pneumococcal vaccination. This is the numerator.

Quality of patient care = 69/112. Dr. Petrov has a score of 61.6% for this measure. This translates to 5.0 to 5.9 points when reporting by registry.

Important note

Because of how this measure is structured, physicians score 3 points even if they report on only one patient. Physicians receive no additional score for reporting scores that fall below 30.23%. For example, if Dr. Petrov reported on one patient encounter, she would earn 3 points.


Click on image to download PDF.

Quality measure score benchmark

CMS will award points based on a comparison of your performance rate to CMS benchmarks listed below. Reach the performance rate listed to achieve the corresponding points per measure. Points achieved for the Quality category will account for 45% of the overall MIPS score.

Benchmarks for registry submissions

The table below shows CMS benchmarks for registry submissions. 

Below 3Decile 3Decile 4Decile 5Decile 6Decile 7Decile 8Decile 9
Performance rate  1 patient  30.23 - 
44.52
 44.53- 
55.55
55.56 - 
63.63
63.64 - 
70.42
70.43 - 
76.37
 76.38- 
83.76
83.77 - 
95.44 
>= 
95.45
Points  3 points  3 - 3.9  4 - 4.9 5 - 5.9 6 - 6.9 7 - 7.9 8 - 8.9 9 - 9.9 10
Benchmarks for EHR submissions

The table below shows CMS benchmarks for EHR submissions. 

Below 3Decile 3Decile 4
Decile 5Decile 6Decile 7
Decile 8Decile 9
Performance rate  1 patient  19.01 - 
31.06
 31.07- 
42.70
42.71 - 
53.43
53.44 - 
62.85
62.86 - 
71.81
 71.82- 
80.42
80.43 - 
90.40
>= 90.41 
Points  3 points  3 - 3.9  4 - 4.9 5 - 5.9 6 - 6.9 7 - 7.9 8 - 8.9 9 - 9.9 10
Benchmarks for claims submissions

The table below shows CMS benchmarks for claims submissions. 

Below 3 
Decile 3Decile 4Decile 5Decile 6
Decile 7
Decile 8Decile 9Decile 10
Performance rate  1 patient  49.76 - 
61.10
 61.11- 
70.10
70.11 - 
77.31
77.32- 
82.95
82.96 - 
89.43
 89.44- 
95.66
95.67 - 99.99  100
Points  3 points  3 - 3.9  4 - 4.9 5 - 5.9 6 - 6.9 7 - 7.9 8 - 8.9 9 - 9.9 10

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