Product Lines:
Advantage MD, EHP, Priority Partners, and USFHP.

Measurement Period: January 1–December 31.

Definition:
The percentage of persons 19 years of age and older who are up to date on recommended routine vaccines for influenza, tetanus and diphtheria (Td) or tetanus, diphtheria and acellular pertussis (Tdap), zoster, pneumococcal, hepatitis B and coronavirus disease 2019 (COVID-19).

Stratifications:
Influenza and Td/Tdap: Age as of the start of the measurement period.

• 19–64 years.
• 65 years and older.

Zoster: Age as of the start of the measurement period.

• 50–64 years.
• 65 years and older.

Pneumococcal and COVID-19: Age as of the start of the measurement period.

• 65 years and older.

Hepatitis B: Age as of the start of the measurement period.

• 19–30 years.
• 31–59 years.

Report stratification by race and ethnicity.

Measure Reporting:
CMS Start Rating Measure for Annual Flu Vaccine.
HealthChoice Performance Measure reporting for Priority Partners.

Improvement Notation:
Increased score indicates improvement.

Data Collection:

• ECDS.

Initial Population:

• Measure Item Count: Person.
• Age.
  • Initial populations 1 and 2: 19 years of age and older at the start of the measurement period.
  • Initial population 3: 50 years of age and older at the start of the measurement period.
  • Initial populations 4 and 6: 65 years of age and older at the start of the measurement period.
  • Initial population 5: 19–59 years of age at the start of the measurement period.
• Benefits: Medical.
• Continuous Enrollment: The measurement period.
• Allowable Gap: No more than one gap of ≤45 days during the measurement period. No gaps on the last day of the measurement period.

Denominator:

Denominator 1 and Denominator 2: Immunization status—Influenza and Td/Tdap.
The initial populations 1 and 2 minus denominator exclusions.

Denominator 3: Immunization status—Zoster.
The initial population 3 minus denominator exclusions.

Denominator 4 and Denominator 6: Immunization status—Pneumococcal and COVID-19.
The initial populations 4 and 6 minus denominator exclusions.

Denominator 5: Immunization status—Hepatitis B.
The initial population 5 minus denominator exclusions.

Summary of changes:
Added the COVID-19 indicator for adults 65 and older. This indicator is in first-year status for measurement year 2026.

Best Practice and Measure Tips

• Advise patient on the importance of completing each vaccine series.
  • Provide handouts.
  • Educate members on vaccination and side effects.
  • Review immunization records at each visits and catch up with any missing immunizations.
• Office improvement opportunity
  • Place guidelines to schedule visits within the CDC guidelines timeframe. Reference the CDC Immunization Vaccine Schedule.
  • Contact member to re-schedule any missed appointment for their vaccination.
  • Use your electronic medical record (EMR) to set flags with immunization gap timeframes.
  • Ensure that members’ medical records include immunization history from all sources.
  • Train medical staff to answer questions about vaccinations, administer vaccinations, and document vaccinations.
  • Use measure codes and exclusion code listed below when submitting claims to make member compliant by administrative data.
  • DOCUMENT ANY PATIENT REFUSAL FOR IMMUNIZATIONS. This does not exclude member from measure.
  • The below count towards compliance for the vaccine. Document with event date:
    • Anaphylaxis due to the vaccine.
    • Evidence of the antigen or combination vaccine.
    • Documented history of the illness.

Acceptable documentation:

• A certificate of immunization prepared by an authorized health care provider or agency including the specific dates and types of immunizations administered.
• A note indicating the name of the specific antigen and immunization date.

Not Acceptable:

• A note the "member is up to date" with all immunizations but does not list the dates and names of all immunizations.

Measure Exclusions

Denominator Exclusions:

• Persons in hospice or using hospice services any time during the measurement period.
• Persons who died any time during the measurement period.

Measure Codes

Adult Influenza

• CPT: 90653, 90656, 90658, 90661, 90662, 90673, 90674, 90682, 90686, 90688, 90689, 90694, 90756
• CVX: 88, 135, 140, 141, 144, 150, 153, 155, 158, 166, 168, 171, 185, 186, 197, 205, 320
• Anaphylaxis due to the influenza vaccine SNOMED CT: 471361000124100

Influenza Virus LAIV

• CPT: 90660, 90672
• CVX: 111, 149

Td

•  CPT: 90714
• CVX: 09, 113, 138, 139

Tdap

• CPT: 90715
• CVX: 115

Td/Tdap

• Anaphylaxis Due to Diphtheria, Tetanus or Pertussis Vaccine:
• SNOMED CT: 428281000124107, 428291000124105
• Encephalitis Due to Diphtheria, Tetanus or Pertussis Vaccine SNOMED CT: 192710009, 192711008, 192712001

Zoster

• CPT: 90750
• CVX: 187
• Anaphylaxis Due to Herpes Zoster Vaccine SNOMED CT: 471371000124107, 471381000124105

Pneumococcal

• CPT: 90670, 90671, 90677, 90684, 90732
• HCPCS: G0009
• CVX: 33, 109, 133, 152, 215, 216, 327
• Anaphylaxis Due to the pneumococcal vaccine SNOMED CT: 471141000124102

Hepatitis B

• Childhood hepatitis B vaccine
  • CPT: 90697, 90723, 90740, 90744, 90747, 90748
  • HCPCS: G0010
  • CVX: 08, 44, 45, 51, 110, 146, 198
  • One of the three vaccinations can be a newborn hepatitis B vaccination ICD-10-PCS: 3E0234Z
• Adult hepatitis B vaccine
  • Two (2) dose
    • CPT: 90739, 90743
    • CVX: 189
• Three (3) dose
  • CPT: 90740, 90744, 90746, 90747, 90759
  • CVX: 43, 44, 45, 104, 220
• Hepatitis B antigen lab test
  • A hepatitis B test with threshold of 10 with a result greater than 10 mIU/mL LOINC: 16935-9, 49495-5, 5193-8
  • A hepatitis B pre-vaccination test with a hepatitis B finding of immunity.
    • Pre-vaccination Tests LOINC: 10900-9, 13919-6, 13952-7, 16933-4, 16935-9, 22316-4, 22318-0, 22319-8, 22322-2, 24113-3, 31204-1, 32019-2, 32685-0, 39535-0, 40725-4, 48070-7, 49177-9, 5185-4, 5186-2, 5187-0, 5188-8, 51914-0, 5193-8, 5194-6, 5195-3, 5196-1, 5197-9, 58405-2, 58452-4, 63557-3, 65633-0, 70154-0, 75378-0, 75409-3, 75410-1, 7905-3, 83100-8, 95234-1, 99385-7, 104785-1
    • Immunity finding SNOMED CT: 105811000119100, 10828004, 165806002, 260373001, 271511000, 313234004, 406117000, 736687002
• History of hepatitis B illness
• ICD-10-CM: B16.0, B16.1, B16.2, B16.9, B17.0, B18.0, B18.1, B19.10, B19.11
• SNOMED CT US Edition: 1116000, 13265006, 26206000, 38662009, 50167007, 53425008, 60498001, 61977001, 66071002, 76795007, 111891008, 165806002, 186624004, 186626002, 186639003, 235864009, 235865005, 235869004, 235871004, 271511000, 313234004, 406117000, 424099008, 424340000, 429721005, 442134007, 442374005, 446698005, 838380002, 1230342001, 59851000119103, 153091000119109, 551621000124109, 16859701000119109
• Anaphylaxis due to the hepatitis B vaccine SNOMED CT code 428321000124101

Adult COVID19

• CPT: 91304, 91320, 91322
• CVX: 309, 312, 313
• Anaphylaxis due to the COVID-19 vaccine SNOMED CT code 914587451000119107