Childhood Immunization Status

Last updated: March 21, 2017

CMS Measure ID: CMS117v5
Version: 5
NQF Number: 0038
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 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 Patient Population:

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

Denominator Statement:

Equals Initial Population

Denominator Exclusions:

None

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

Measure Steward: National Committee for Quality Assurance
Domain: Community/Population Health
Previous Version: Childhood Immunization Status
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.

Specifications

Release Notes

Header

  • Updated Clinical Recommendation Statement.

    Section: Clinical Recommendation Statement

    Source: Measure Lead

  • ‚ÄčUpdated Copyright.

    Section: Copyright

    Source: Annual Update

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Annual Update

  • Clarified the guidance around what events were allowable for numerator compliance.

    Section: Guidance

    Source: Measure Lead

  • Updated Improvement Notation.

    Section: Improvement Notation

    Source: Measure Lead

  • Updated References.

    Section: Reference

    Source: Measure Lead

Logic

  • Reordered numerator statements so all vaccinations follow the same pattern.

    Section: Numerator

    Source: Measure Lead

  • Replaced datatypes 'Diagnosis, Active; Diagnosis, Inactive; Diagnosis, Resolved' with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: Numerator

    Source: QDM Standards

  • Replaced 'Medication' QDM category with 'Immunization' QDM category for instances associated with a vaccination/immunization value set (CVX) to conform to QDM 4.2 changes.

    Section: Numerator

    Source: QDM Standards

  • Updated 'hours' to 'days' for the timing between Rotavirus 3 shots to align the timing with the other vaccinations.

    Section: Numerator

    Source: JIRA (CQM-1581)

  • Value set Encephalopathy (2.16.840.1.113883.3.464.1003.114.12.1007): Renamed Encephalopathy to Encephalopathy due to Childhood Vaccination.

    Section: Numerator

    Source: None

  • Value set Hemophilus Influenze B (HiB) Vaccine (2.16.840.1.113883.3.464.1003.196.12.1217): Renamed Hemophilus Influenze B (HiB) Vaccine to Haemophilus Influenzae Type B (HiB) Vaccine.

    Section: Numerator

    Source: None

  • Value set Hemophilus Influenze B (HiB) Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1043): Renamed Hemophilus Influenze B (HiB) Vaccine Administered to Haemophilus Influenzae Type B (HiB) Vaccine Administered.

    Section: Numerator

    Source: None

  • Value set Malignant Neoplasm of Lymphatic and Hematopietic Tissue (2.16.840.1.113883.3.464.1003.108.12.1009): Renamed Malignant Neoplasm of Lymphatic and Hematopietic Tissue to Malignant Neoplasm of Lymphatic and Hematopoietic Tissue.

    Section: Numerator

    Source: None

  • Replaced datatypes 'Diagnosis, Active; Diagnosis, Inactive; Diagnosis, Resolved' with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: QDM Data Elements

    Source: QDM Standards

  • Replaced 'Medication' QDM category with 'Immunization' QDM category for instances associated with a vaccination/immunization value set (CVX) to conform to QDM 4.2 changes.

    Section: QDM Data Elements

    Source: QDM Standards

  • Value set Encephalopathy (2.16.840.1.113883.3.464.1003.114.12.1007): Renamed Encephalopathy to Encephalopathy due to Childhood Vaccination.

    Section: QDM Data Elements

    Source: None

  • Value set Hemophilus Influenze B (HiB) Vaccine (2.16.840.1.113883.3.464.1003.196.12.1217): Renamed Hemophilus Influenze B (HiB) Vaccine to Haemophilus Influenzae Type B (HiB) Vaccine.

    Section: QDM Data Elements

    Source: None

  • Value set Hemophilus Influenze B (HiB) Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1043): Renamed Hemophilus Influenze B (HiB) Vaccine Administered to Haemophilus Influenzae Type B (HiB) Vaccine Administered.

    Section: QDM Data Elements

    Source: None

  • Value set Malignant Neoplasm of Lymphatic and Hematopietic Tissue (2.16.840.1.113883.3.464.1003.108.12.1009): Renamed Malignant Neoplasm of Lymphatic and Hematopietic Tissue to Malignant Neoplasm of Lymphatic and Hematopoietic Tissue.

    Section: QDM Data Elements

    Source: None

  • Replaced 'Medication' QDM category with 'Immunization' QDM category for instances associated with a vaccination/immunization value set (CVX) to conform to QDM 4.2 changes.

    Section: QDM Variables

    Source: QDM Standards

Value Set

  • Value set Disorders of the Immune System (2.16.840.1.113883.3.464.1003.120.12.1001): Deleted 1 SNOMEDCT code (191352003).

    Section: None

    Source: None

  • Value set Encephalopathy (2.16.840.1.113883.3.464.1003.114.12.1007): Renamed Encephalopathy to Encephalopathy due to Childhood Vaccination.

    Section: None

    Source: None

  • Value set Hemophilus Influenze B (HiB) Vaccine (2.16.840.1.113883.3.464.1003.196.12.1217): Renamed Hemophilus Influenze B (HiB) Vaccine to Haemophilus Influenzae Type B (HiB) Vaccine.

    Section: None

    Source: None

  • Value set Hemophilus Influenze B (HiB) Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1043): Renamed Hemophilus Influenze B (HiB) Vaccine Administered to Haemophilus Influenzae Type B (HiB) Vaccine Administered.

    Section: None

    Source: None

  • Value set Hepatitis A (2.16.840.1.113883.3.464.1003.110.12.1024): Deleted 1 SNOMEDCT code (186621007).

    Section: None

    Source: None

  • Value set Hepatitis B (2.16.840.1.113883.3.464.1003.110.12.1025): Deleted 1 SNOMEDCT code (186623005).

    Section: None

    Source: None

  • Value set HIV (2.16.840.1.113883.3.464.1003.120.12.1003): Added 1 ICD9CM code (079.53). Added 1 ICD10CM code (B97.35).

    Section: None

    Source: None

  • Value set Malignant Neoplasm of Lymphatic and Hematopietic Tissue (2.16.840.1.113883.3.464.1003.108.12.1009): Renamed Malignant Neoplasm of Lymphatic and Hematopietic Tissue to Malignant Neoplasm of Lymphatic and Hematopoietic Tissue.

    Section: None

    Source: None

  • Value set Hepatitis B (2.16.840.1.113883.3.464.1003.110.12.1025): Deleted 1 ICD10CM code (Z22.51).

    Section: None

    Source: ICD-10 Addendum

External Resources