Who is eligible for MIPS 394?

DENOMINATOR (SUBMISSION CRITERIA FOR ALL RATES): Adolescents who turn 13 years of age during the measurement period.

Is MIPS 394 the same as MIPS 394?

Yes. CMS uses zero-padded three-digit Quality IDs (394) in official specifications, while clinicians often search for MIPS 394 or Quality ID 394 without the leading zero. Both refer to the same 2026 MIPS quality measure reported through the Quality Payment Program (QPP).

How do I report MIPS Measure 394 in 2026?

MIPS Measure 394 (Quality ID 394) is reported through the Quality Payment Program (QPP) as a MIPS Clinical Quality Measure (CQM) via qualified registry, or Medicare Part B claims where applicable.

Is MIPS 394 a topped-out measure?

No, MIPS 394 is not topped out, meaning there is still meaningful performance variation across clinicians.

Measure ID: MIPS 394|Immunization|2026 Performance Year

2026 MIPS Measure #394: Immunizations for Adolescents

The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine (serogroups A, C, W, Y or A, C, W, Y, B), one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the Human Papillomavirus (HPV) vaccine series by their 13th birthday.

ProcessImmunizationPreventive Care

Measure ID:MIPS 394 (Quality ID 394)

Collection:MIPS CQM

Topped Out:No

View CMS Spec ↗

Measure Specification

This measure produces 4 performance rates. Each rate has its own eligible population, numerator, and reporting codes.

Criteria 1

Eligible Population

Patients who turn 13 years of age during the measurement period

ANDPatient encounter during the performance period

Exclusions

G9761Patients who use hospice services any time during the measurement period

Numerator

Adolescents who had one dose of meningococcal vaccine (serogroups A, C, W, Y or A, C, W, Y, B), on or between the patient’s 10th and 13th birthdays.

Reporting Codes

Performance Met:

G9414Patient had one dose of meningococcal vaccine (serogroups A, C, W, Y or A, C, W, Y, B) on or between the patient’s 10th and 13th birthdays

Performance Not Met:

G9415Patient did not have one dose of meningococcal vaccine (serogroups A, C, W, Y or A, C, W, Y, B), on or between the patient’s 10th and 13th birthdays NUMERATOR (PERFORMANCE RATE 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:

○ Exceptions:

M1160Patient had anaphylaxis due to the meningococcal vaccine any time on or before the patient’s 13th birthday

Performance Rate 2

Eligible Population

Patients who turn 13 years of age during the measurement period

ANDPatient encounter during the performance period

Exclusions

G9761Patients who use hospice services any time during the measurement period

Numerator

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

Reporting Codes

Performance Met:

G9416Patient had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays

Performance Not Met:

G9417Patient did not have one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays NUMERATOR (PERORMANCE RATE 3): Adolescents who completed the HPV vaccine series on or between the patient’s 9th and 13th birthdays. Numerator Options:

○ Exceptions:

M1161Patient had anaphylaxis due to the tetanus, diphtheria or pertussis vaccine any time on or before the patient’s 13th birthday

Performance Rate 3

Eligible Population

Patients who turn 13 years of age during the measurement period

ANDPatient encounter during the performance period

Exclusions

G9761Patients who use hospice services any time during the measurement period

Numerator

Adolescents who completed the HPV vaccine series on or between the patient’s 9th and 13th birthdays.

Reporting Codes

Performance Met:

G9762Patient had at least two HPV vaccines (with at least 146 days between the two) OR three HPV vaccines on or between the patient’s 9th and 13th birthdays

Performance Not Met:

G9763Patient did not have at least two HPV vaccines (with at least 146 days between the two) OR three HPV vaccines on or between the patient’s 9th and 13th birthdays NUMERATOR (PERFORMANCE RATE 4): Adolescents who are numerator compliant for Rates 1, 2 and 3.

○ Exceptions:

M1162Patient had encephalitis due to the tetanus, diphtheria or pertussis vaccine any time on or before the patient’s 13th birthday

Performance Rate 4

Eligible Population

Patients who turn 13 years of age during the measurement period

ANDPatient encounter during the performance period

Exclusions

G9761Patients who use hospice services any time during the measurement period

Numerator

Adolescents who are numerator compliant for Rates 1, 2 and 3.

Reporting Codes

○ Exceptions:

M1163Patient had anaphylaxis due to the HPV vaccine any time on or before the patient’s 13th birthday

VBCA Insights

Why This Measure Matters

By age 13, has the adolescent received meningococcal and Tdap vaccines and completed the HPV series? This measure tracks three vaccines that prevent serious, sometimes fatal infections (meningitis, pertussis, certain cancers). Good performance requires systematic identification of eligible adolescents, standing orders or reminder systems, and addressing barriers like cost or hesitancy. HPV vaccination in early adolescence prevents future cervical and oropharyngeal cancers; closing these gaps saves lives.

VBCA is a CMS-approved Qualified Clinical Data Registry (QCDR) that submits MIPS Measure 394 to the Quality Payment Program (QPP). Practices can report this measure as a MIPS Clinical Quality Measure (CQM) or through qualified registry submission.

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Specialty Measure Sets

Family Medicine Infectious Disease Pediatrics

Related Measures

Immunization

MIPS 493: Adult Immunization Status

Preventive Care

MIPS 039: Screening for Osteoporosis for Women Aged 65-85 Years of Age MIPS 112: Breast Cancer Screening MIPS 113: Colorectal Cancer Screening MIPS 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan MIPS 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation MIPS 317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up MIPS 320: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients MIPS 336: Maternity Care: Postpartum Follow-up and Care Coordination MIPS 398: Optimal Asthma Control MIPS 431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief MIPS 493: Adult Immunization Status MIPS 497: Preventive Care and Wellness (Composite)

Official Resources

📄 CMS Measure Specification (PDF)🔗 QPP Quality Payment Program

Clinical Rationale

This measure assesses the percentage of adolescents 13 years of age who had one dose of meningococcal vaccine, one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday. The measure calculates a rate for each vaccine and two combination rates. This measure follows the Advisory Committee on Immunization Practices (ACIP) guidelines for immunizations.

[1],[2],[3] These vaccines are available for adolescents to prevent them from acquiring serious diseases and help protect against disease in populations that lack immunity, such as infants, the elderly and individuals with chronic conditions.

Clinical Recommendations

The Advisory Committee on Immunization Practices (ACIP) recommends routine HPV vaccination for adolescents at age 11 or 12 years; vaccination may be given starting at age 9 years. In a two-dose schedule of HPV vaccine, the minimum interval between the first and second doses is 5 months. Persons who initiated vaccination with 9vHPV, 4vHPV or 2vHPV before their 15th birthday and received 2 doses of any HPV vaccine at the recommended dosing schedule (0, 6–12 months), or received three doses of any HPV vaccine at the recommended dosing schedule (0, 1–2, 6 months), are considered adequately vaccinated (Meites, Kempe, and Markowitz 2016).

ACIP recommends a single dose of the Tdap vaccine be administered at age 11 or 12 years (Liang et al. 2018). ACIP recommends routine vaccination with a quadrivalent meningococcal conjugate vaccine for adolescents aged 11 or 12 years, with a booster dose at age 16 years (Mbaeyi et al. 2020). In certain situations, a pentavalent vaccine may be administered to persons aged 10 years and older when both a quadrivalent meningococcal conjugate vaccine and meningococcal B vaccine are indicated at the same visit (Collins et al.

2024).

Implementation Notes

This measure contains four strata defined by a single submission criteria. This measure produces four performance rates. This measure will be calculated with 4 performance rates: 1) Patients who had one dose of meningococcal vaccine (serogroups A, C, W, Y or A, C, W, Y, B), on or between the patient’s 10th and 13th birthdays. 2) Patients who had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays.

3) Patients who have completed the HPV vaccine series with different dates of service on or between the patient’s 9th and 13th birthdays. 4) All patients who are compliant for Meningococcal (serogroups A, C, W, Y), Tdap and HPV during the specified timeframes. For accountability reporting in the CMS MIPS program, the rate for Submission Criteria 4 is used for performance.

For the purposes of MIPS implementation of this measure, this patient-process measure is submitted a minimum of once per patient during the performance period. The most advantageous quality data code (QDC) will be used if the measure is submitted more than once.

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