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Childhood Immunization Status

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Measure Information 2022 Performance Period
CMS eCQM ID CMS117v10
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 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
Numerator Exclusions

Not Applicable
Denominator Exceptions

None
Measure Steward National Committee for Quality Assurance
Measure Scoring Proportion measure
Measure Type Process measure
Improvement Notation

Higher score equals better quality
Guidance

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 for more information on the QDM.
MIPS Quality ID 240
Telehealth Eligible Yes
Next Version
CMS117v11
Previous Version
CMS117v9

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Measure Information 2021 Performance Period 2022 Performance Period 2023 Performance Period
Title Childhood Immunization Status Childhood Immunization Status Childhood Immunization Status
CMS eCQM 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 • Intussusception Exclude 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
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 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
Telehealth Eligible Yes Yes Yes
Next Version CMS117v10 CMS117v11 No Version Available
Previous Version No Version Available
CMS117v9
CMS117v10
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Specifications
Attachment Size
CMS117v10.html 144.3 KB
CMS117v10.zip 156.47 KB
CMS117v10-TRN.xlsx 20.59 KB

*Note: There is a known issue on CMS117v10. See issue EKI-16 on the ONC eCQM Known Issues Dashboard for details.

Data Element Repository

Value Sets
Value Sets to be used with CMS117v10

Release Notes

CMS117v10-TRN.xlsx

Header

  • Updated the eCQM version number.

    Measure Section: eCQM Version Number

    Source of Change: Annual Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated the clinical recommendation statement to align with current clinical recommendations.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Annual Update

  • Revised the guidance to clarify the measure intent and numerator criteria.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Replaced 'overlaps' or 'overlapping' in the denominator exclusions with plain language to clarify the measure intent.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

Logic

  • Revised the initial population to remove lower age boundary.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Added definitions 'LAIV Vaccinations' and 'Two Influenza Vaccinations Including One LAIV Vaccination' to the numerator to to allow for patients 2 years of age to receive an influenza LAIV vaccination as one of the two recommended influenza immunization doses.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Replaced the 'Anaphylactive Reaction to Hepatitis A Vaccine' value set with a direct reference code 'Adverse reaction to vaccine product containing Hepatitis A virus antigen' in the Hepatitis A Numerator Inclusion Conditions definition.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated select numerator definitions with current SNOMED code descriptions.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.

    Measure Section: Functions

    Source of Change: Standards Update

  • Added the definition 'Date of Second Birthday' to clarify the timing for patient's second birthday for numerator criteria.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Added online assessments and telephone visits as appropriate encounters based on the increased use of telehealth services.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated Hospice CQL Library to version 3.0.000.

    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 Measles, Mumps and Rubella (MMR) Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1031): Added 2 SNOMED CT codes (571591000119106, 572511000119105) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Rubella (2.16.840.1.113883.3.464.1003.110.12.1037): Deleted 2 SNOMED CT codes (111867004, 84611003) based on validity of code during timing of look back period.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Hepatitis A Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1041): Added 3 SNOMED CT codes (871752004, 871753009, 871754003) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Inactivated Polio Vaccine (IPV) Administered (2.16.840.1.113883.3.464.1003.110.12.1045): Added 21 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Measles (2.16.840.1.113883.3.464.1003.110.12.1053): Added 1 SNOMED CT code (359686005) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Removed value set Anaphylactic Reaction to Hepatitis A Vaccine (2.16.840.1.113883.3.464.1003.199.12.1026) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Hepatitis B (2.16.840.1.113883.3.464.1003.110.12.1025): Added 1 SNOMED CT code (838380002) based on terminology update.

    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 61 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 28 SNOMED CT codes based on validity of code during timing of look back period.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set DTaP Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1022): Added 13 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Disorders of the Immune System (2.16.840.1.113883.3.464.1003.120.12.1001): Added 12 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 2 SNOMED CT codes (234603007, 25109007) based on review by technical experts, SMEs, and/or public feedback. Added 10 ICD-10-CM codes (D84.81, D84.821, D84.822, D84.89, D89.831, D89.832, D89.833, D89.834, D89.835, D89.839) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Severe Combined Immunodeficiency (2.16.840.1.113883.3.464.1003.120.12.1007): Deleted 1 SNOMED CT code (203592006) based on validity of code during timing of look back period.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Intussusception (2.16.840.1.113883.3.464.1003.199.12.1056): Added 3 SNOMED CT codes (26316005, 64976006, 91446004) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 SNOMED CT code (197048002) based on validity of code during timing of look back period.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Varicella Zoster (2.16.840.1.113883.3.464.1003.110.12.1039): Added 11 SNOMED CT codes (15685201000119100, 15685281000119108, 15936581000119108, 15936621000119108, 15989271000119107, 15989311000119107, 15989351000119108, 15991711000119108, 15991791000119104, 838357005, 98541000119101) based on review by technical experts, SMEs, and/or public feedback. Deleted 3 SNOMED CT codes (15681321000119100, 15681401000119101, 186525007) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Hepatitis B Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1042): Added 6 SNOMED CT codes (572561000119108, 770608009, 770616000, 770618004, 786846001, 787438002) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 SNOMED CT code (116802006) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Influenza Virus LAIV Immunization (2.16.840.1.113883.3.464.1003.110.12.1087) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Influenza Virus LAIV Procedure (2.16.840.1.113883.3.464.1003.110.12.1088) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Online Assessment (2.16.840.1.113883.3.464.1003.101.12.1089) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set HIV (2.16.840.1.113883.3.464.1003.120.12.1003): Added 9 SNOMED codes (838377003, 840498003, 10755671000119100, 15928141000119107, 771119002, 771126002, 771127006, 72631000119101, 840442003) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Added direct reference code CPT code (99211) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jan 27, 2023