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Childhood Immunization Status

Measure Information 2021 Performance Period
CMS Measure ID CMS117v9
NQF Number Not Applicable
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

Equals Initial Population

Denominator Exclusions

Exclude patients whose hospice care overlaps the measurement period

Numerator

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
Quality Domain Community/Population Health
Measure Scoring Proportion measure
Measure Type Process measure
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, 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 varicella vaccines if they have cancer of lymphoreticular or histiocytic tissue, multiple myeloma, leukemia, have had an anaphylactic reaction to neomycin, have immunodeficiency, 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.

This eCQM is a patient-based measure.

 

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

MIPS Quality ID 240
Meaningful Measure Preventive Care
Telehealth Eligible Yes
Next Version
Previous Version No Version Available

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Measure Information 2021 Performance Period 2022 Performance Period 2023 Performance Period
Name Childhood Immunization Status Childhood Immunization Status Childhood Immunization Status
CMS Measure ID CMS117v9 CMS117v10 CMS117v11
NQF Number Not Applicable Not Applicable Not Applicable
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

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

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

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

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

Denominator

Equals Initial Population

Equals Initial Population

Equals Initial Population

Denominator Exclusions Exclude patients whose hospice care overlaps the measurement period Exclude patients who are in hospice care for any part of the measurement period. Exclude children with any of the following on or before the child’s second birthday:• Severe combined immunodeficiency• Immunodeficiency• HIV• Lymphoreticular cancer, multiple myeloma or leukemia• IntussusceptionExclude children who are in hospice care for any part of the measurement period.
Numerator

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

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

Diphtheria, tetanus, and pertussis (DTaP) vaccination

Children with any of the following on or before the child’s second birthday meet criteria:

• At least four DTaP vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth.

• Anaphylaxis due to the diphtheria, tetanus or pertussis vaccine.

• Encephalitis due to the diphtheria, tetanus or pertussis vaccine.

Poliovirus vaccination (IPV)

At least three IPV vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.

Measles, mumps, and rubella vaccination (MMR)

Children with either of the following meet criteria:

• At least one MMR vaccination on or between the child’s first and second birthdays.

• All of the following anytime on or before the child’s second birthday (on the same or different date of service):

o History of measles

o History of mumps

o History of rubella

Haemophilus influenzae type b vaccination (HiB)

Children with either of the following meet criteria on or before the child’s second birthday:

• At least three HiB vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth.

• Anaphylaxis due to the HiB vaccine.

Hepatitis B

Children with any of the following on or before the child’s second birthday meet criteria:

• At least three hepatitis B vaccinations, with different dates of service.

o One of the three vaccinations can be a newborn hepatitis B vaccination during the eight-day period that begins on the date of birth and ends seven days after the date of birth. For example, if the member’s date of birth is December 1, the newborn hepatitis B vaccination must be on or between December 1 and December 8.

• Anaphylaxis due to the hepatitis B vaccine.

• History of hepatitis B illness.

Varicella vaccination (VZV)

Children with either of the following meet criteria:

• At least one VZV vaccination, with a date of service on or between the child’s first and second birthdays.

• History of varicella zoster (e.g., chicken pox) illness on or before the child’s second birthday.

Pneumococcal Conjugate

At least four pneumococcal conjugate vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.

Hepatitis A

Children with either of the following meet criteria:

• At least one hepatitis A vaccination, with a date of service on or between the child’s first and second birthdays.

• History of hepatitis A illness on or before the child’s second birthday.

Rotavirus

Children with any of the following meet criteria:

• At least two doses of the two-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.

• At least three doses of the three-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.

• At least one dose of the two-dose rotavirus vaccine and at least two doses of the three-dose rotavirus vaccine, all on different dates of service, on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.

• Anaphylaxis due to the rotavirus vaccine on or before the child’s second birthday.

Influenza

At least two influenza vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 6 months (180 days) after birth.

• One of the two vaccinations can be an LAIV vaccination administered on the child’s second birthday. Do not count an LAIV vaccination administered before the child’s second birthday.

Numerator Exclusions

Not Applicable

Not Applicable

Not Applicable

Denominator Exceptions

None

None

None

Measure Steward National Committee for Quality Assurance National Committee for Quality Assurance National Committee for Quality Assurance
Quality Domain Community/Population Health Community/Population Health Community/Population Health
Measure Scoring Proportion measure Proportion measure Proportion measure
Measure Type Process measure Process measure Process measure
Improvement Notation

Higher score equals better quality

Higher score equals better quality

Higher score indicates 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, 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 varicella vaccines if they have cancer of lymphoreticular or histiocytic tissue, multiple myeloma, leukemia, have had an anaphylactic reaction to neomycin, have immunodeficiency, 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.

This eCQM is a patient-based measure.

 

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

Numerator criteria includes evidence of receipt of the recommended vaccine or the following:

-- DTaP:

Adverse reaction to the DTaP or Td vaccine; or encephalopathy due to DTaP or Td vaccination

-- Polio (IPV) vaccine:

Adverse reaction to the IPV vaccine, streptomycin, polymyxin B, or neomycin

-- MMR Vaccination:

Immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma, or leukemia; adverse reaction to neomycin; history of measles, mumps, or rubella; or a seropositive result for the antigens

-- Hib:

Adverse reaction to the Hib vaccine

-- Hepatitis B:

Seropositive result for the antigen, adverse reaction to the hepatitis B vaccine, adverse reaction to common baker’s yeast, or a history of hepatitis B illness

-- Chicken pox (varicella zoster):

Seropositive result for the antigen; immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma, or leukemia; adverse reaction to neomycin; or a history of varicella zoster

-- Pneumococcal:

Adverse reaction to the pneumococcal vaccine

-- Hepatitis A:

Seropositive result for the antigen, adverse reaction to the hepatitis A vaccine, or a history of hepatitis A illness

-- Rotavirus:

Adverse reaction to the rotavirus vaccine, severe combined immunodeficiency, or a history of intussusception

-- Influenza:

Adverse reaction to the influenza vaccine; immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma, or leukemia; or adverse reaction to neomycin

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

This eCQM is a patient-based measure.

 

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

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

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

MIPS Quality ID 240 240 240
Meaningful Measure Preventive Care Preventive Care Preventive Care
Telehealth Eligible Yes Yes Yes
Next Version CMS117v10 CMS117v11 No Version Available
Previous Version No Version Available

Release Notes

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Revised to use 'Hib' instead of 'HiB' abbreviation to improve consistency and accuracy.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​Updated the Rationale to remove outdated references and content and to update references.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Revised to use 'Hib' instead of 'HiB' abbreviation to improve consistency and accuracy.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated the Clinical Recommendations Statement to remove outdated references and update with the most recent clinical recommendations.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Standards Update

  • Updated the guidance to remove 'conjugate' and 'VZV' and add 'Varicella' for additional clarification.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Added text to identify the Quality Data Model (QDM) version used in the measure specification.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Added text to indicate whether the measure is patient-based or episode-based.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Revised to use 'Hib' instead of 'HiB' abbreviation to improve consistency and accuracy.

    Measure Section: Guidance

    Source of Change: Measure Lead

Logic

  • Revised to use 'Hib' instead of 'HiB' abbreviation to improve consistency and accuracy.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Revised to use 'Hib' instead of 'HiB' abbreviation to improve consistency and accuracy.

    Measure Section: Definitions

    Source of Change: Measure Lead

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

    Measure Section: Definitions

    Source of Change: Standards Update

  • Updated timing logic for the follow-up assessment to use 'in Interval' to simplify logic and promote harmonization between measures.

    Measure Section: Definitions

    Source of Change: Measure Lead

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

    Measure Section: Functions

    Source of Change: Standards Update

  • CQL Library version update: Updated version number of the Hospice Library (Hospice-2.2.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated CQL expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000). Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

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 HIV (2.16.840.1.113883.3.464.1003.120.12.1003): Deleted 15 SNOMED CT codes based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.464.1003.110.12.1083): Renamed to Hib Vaccine (3 dose schedule).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.464.1003.110.12.1084): Renamed to Hib Vaccine (3 dose schedule) Administered.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.464.1003.110.12.1085): Renamed to Hib Vaccine (4 dose schedule).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.464.1003.110.12.1086): Renamed to Hib Vaccine (4 dose schedule) Administered.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: May 04, 2022