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Childhood Immunization Status

CMS Measure ID
CMS117v8
Version
8
NQF Number
Not Applicable
Measure Description

Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three or four H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday

Initial Population

Children who turn 2 years of age during the measurement period and who have a visit during the measurement period

Denominator Statement
Denominator Exclusions

Exclude patients whose hospice care overlaps the measurement period

Numerator Statement

Children who have evidence showing they received recommended vaccines, had documented history of the illness, had a seropositive test result, or had an allergic reaction to the vaccine by their second birthday

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Previous Version
Measure Scoring
Measure Type
Improvement Notation

Higher score equals better quality

Guidance

For the MMR, hepatitis B, VZV and hepatitis A vaccines, numerator inclusion criteria include: evidence of receipt of the recommended vaccine; documented history of the illness; or, a seropositive test result for the antigen. For the DTaP, IPV, HiB, pneumococcal conjugate, rotavirus, and influenza vaccines, numerator inclusion criteria include only evidence of receipt of the recommended vaccine.

Patients may be included in the numerator for a particular antigen if they had an anaphylactic reaction to the vaccine. Patients may be included in the numerator for the DTaP vaccine if they have encephalopathy. Patients may be included in the numerator for the IPV vaccine if they have had an anaphylactic reaction to streptomycin, polymyxin B, or neomycin. Patients may be included in the numerator for the influenza, MMR, or VZV vaccines if they have cancer of lymphoreticular or histiocytic tissue, multiple myeloma, leukemia, have had an anaphylactic reaction to neomycin, have Immunodefiency, or have HIV. Patients may be included in the numerator for the hepatitis B vaccine if they have had an anaphylactic reaction to common baker's yeast.

The measure allows a grace period by measuring compliance with these recommendations between birth and age two.

Quality ID
240
Meaningful Measure

Specifications

Attachment Size
CMS117v8.html 116.87 KB
CMS117v8.zip 143.88 KB
CMS117v8-TRN.xlsx 24 KB

Release Notes

 

Header

  • Updated eCQM version number.

    Measure Section: eCQM Version number

    Source of Change: Measure Lead

  • Updated NQF number to 'Not Applicable.'

    Measure Section: NQF Number

    Source of Change: Standards Update

  • Updated endorsed by field to 'None.'

    Measure Section: Endorsed By

    Source of Change: Standards Update

  • Updated description statement with addition of 4 dose HiB vaccinations to the description of the measure.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated rationale.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated clinical recommendation statement.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated references to align with American Psychological Association (APA) style.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated parenthetical citations to align with American Psychological Association (APA) style.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

 

Logic

  • Updated the logic to use the second birthday (patient birthdate plus 2 years) rather than the 730 day calculation to be more accurate for leap years.

    Measure Section: Numerator

    Source of Change: ONC Project Tracking System (JIRA): CQM-3199

  • Removed definition 'Three HiB Vaccinations' and added new definition statements 'HiB 3 Dose Immunizations or Procedures,' 'HiB 4 Dose Immunizations or Procedures,' 'HiB 3 or 4 Dose Immunizations,' 'All HiB Vaccinations,' and 'Has Appropriate Number of HiB Immunizations.' Revised logic to include the correct number of HiB doses depending on the manufacturer of the vaccine given to align with current guidelines.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with CQL Style Guide.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MAT) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Hospice Library (Hospice-2.0.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

 

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set Hepatitis A (2.16.840.1.113883.3.464.1003.110.12.1024): Added 5 SNOMED CT codes (105801000119103, 165997004, 278971009, 310875001, 428030001).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Measles, Mumps and Rubella (MMR) Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1031): Added SNOMED CT extensional value set (2.16.840.1.113883.3.464.1003.110.11.1086) including 1 code.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Mumps (2.16.840.1.113883.3.464.1003.110.12.1032): Added SNOMED CT extensional value set (2.16.840.1.113883.3.464.1003.110.11.1087) including 3 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Rubella (2.16.840.1.113883.3.464.1003.110.12.1037): Added 4 SNOMED CT codes (161421005, 165792000, 406112006, 406113001).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Varicella Zoster Vaccine (VZV) Administered (2.16.840.1.113883.3.464.1003.110.12.1040): Added 1 SNOMED CT code (473164004) and deleted 1 SNOMED CT code (68525005).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Measles (2.16.840.1.113883.3.464.1003.110.12.1053): Added 3 SNOMED CT codes (105841000119101, 161419000, 371111005).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Encephalopathy due to Childhood Vaccination (2.16.840.1.113883.3.464.1003.114.12.1007): Added 9 SNOMED CT codes (192705005, 192706006, 192707002, 192708007, 192709004, 192713006, 192714000, 192715004, 192716003) and deleted 1 SNOMED CT code (31367003).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Hepatitis B (2.16.840.1.113883.3.464.1003.110.12.1025): Added 5 SNOMED CT codes (165806002, 235865005, 271511000, 313234004, 406117000) and deleted 1 SNOMED CT code (29062009). Deleted 1 ICD-10-CM code (Z22.51).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Malignant Neoplasm of Lymphatic and Hematopoietic Tissue (2.16.840.1.113883.3.464.1003.108.12.1009): Added 1 SNOMED CT code (404146005).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Disorders of the Immune System (2.16.840.1.113883.3.464.1003.120.12.1001): Deleted 1 SNOMED CT code (267538002).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Varicella Zoster (2.16.840.1.113883.3.464.1003.110.12.1039): Added 3 SNOMED CT codes (161423008, 371113008, 681221000119108).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set HIV (2.16.840.1.113883.3.464.1003.120.12.1003): Added 54 SNOMED CT codes and deleted 1 SNOMED CT code (79019005).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Hepatitis B Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1042): Deleted 1 SNOMED CT code (170374009). Added ICD-9-CM extensional value set (2.16.840.1.113883.3.464.1003.110.11.1145) including 1 code. Added ICD-10-PCS extensional value set (2.16.840.1.113883.3.464.1003.110.11.1147) including 1 code.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set HiB Vaccine (3 dose schedule) (2.16.840.1.113883.3.464.1003.110.12.1083): Added HiB Vaccine (3 dose schedule).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set HiB Vaccine (3 dose schedule) Administered (2.16.840.1.113883.3.464.1003.110.12.1084): Added HiB Vaccine (3 dose schedule) Administered.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set HiB Vaccine (4 dose schedule) (2.16.840.1.113883.3.464.1003.110.12.1085): Added HiB Vaccine (4 dose schedule).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set HiB Vaccine (4 dose schedule) Administered (2.16.840.1.113883.3.464.1003.110.12.1086): Added HiB Vaccine (4 dose schedule) Administered.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Haemophilus Influenzae Type B (HiB) Vaccine (2.16.840.1.113883.3.464.1003.196.12.1217): Removed Haemophilus Influenzae Type B (HiB) Vaccine.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Haemophilus Influenzae Type B (HiB) Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1043): Removed Haemophilus Influenzae Type B (HiB) Vaccine Administered.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced direct reference code CPT (90681) with Value set Rotavirus Vaccine (2 dose schedule) Administered (2.16.840.1.113883.3.464.1003.110.12.1048).

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced direct reference code CPT (90680) with Value set Rotavirus Vaccine (3 dose schedule) Administered (2.16.840.1.113883.3.464.1003.110.12.1047).

    Measure Section: Terminology

    Source of Change: Measure Lead

  • The following values sets were added for use in revised numerator logic  related to the HiB vaccines:  'HiB Vaccine (3 dose schedule) Administered' (2.16.840.1.113883.3.464.1003.110.12.1084); 'HiB Vaccine (3 dose schedule)' (2.16.840.1.113883.3.464.1003.110.12.1083); value set 'HiB Vaccine (4 dose schedule) Administered' (2.16.840.1.113883.3.464.1003.110.12.1086), and 'HiB Vaccine (4 dose schedule)' (2.16.840.1.113883.3.464.1003.110.12.1085).

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • ​Removed code system versions from direct reference codes. Please refer to Appendix A of the Electronic Clinical Quality Measure Logic and Implementation Guidance document for a list of code system versions used in the eCQM specifications for 2020 reporting/performance.

    Measure Section: Terminology

    Source of Change: Standards Update

  • Standardized purpose statement language in value sets across eCQMs. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jul 22, 2019