Childhood Immunization Status

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Measure Information	2023 Performance Period	2024 Performance Period	2025 Performance Period
Title	Childhood Immunization Status	Childhood Immunization Status	Childhood Immunization Status
CMS eCQM ID	CMS117v11	CMS117v12	CMS117v13
CBE ID*	Not Applicable	Not Applicable	Not Applicable
MIPS Quality ID	240	240	240
Measure Steward	National Committee for Quality Assurance	National Committee for Quality Assurance	National Committee for Quality Assurance
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 Show more > 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 Show less	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 Show more > 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 Show less	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 (HepB); one chicken pox (VZV); four pneumococcal conjugate (PCV); one... hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday Show more > 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 (HepB); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday Show less
Measure Scoring	Proportion measure	Proportion measure	Proportion measure
Measure Type	Process	Process	Process
Stratification	*See CMS117v11.html	None	None
Risk Adjustment	*See CMS117v11.html	None	None
Rationale	*See CMS117v11.html	Infants and toddlers are particularly vulnerable to infectious diseases because their immune systems have not built up the necessary defenses to fight infection (CDC, 2019). One study estimated that routine childhood vaccines administered in 2019 prevented 24 million diseases (Talbird et... al., 2022). Another recent study estimated that routine childhood vaccinations prevented 17.8 million cases of disease and 31,000 deaths for children born in 2017, in addition to saving $13.7 billion in health care costs (Carrico et al., 2022). Immunizing a child not only protects that child's health but also the health of the community, especially for those who are not immunized or are unable to be immunized due to other health complications (CDC, 2019). Show more > Infants and toddlers are particularly vulnerable to infectious diseases because their immune systems have not built up the necessary defenses to fight infection (CDC, 2019). One study estimated that routine childhood vaccines administered in 2019 prevented 24 million diseases (Talbird et al., 2022). Another recent study estimated that routine childhood vaccinations prevented 17.8 million cases of disease and 31,000 deaths for children born in 2017, in addition to saving $13.7 billion in health care costs (Carrico et al., 2022). Immunizing a child not only protects that child's health but also the health of the community, especially for those who are not immunized or are unable to be immunized due to other health complications (CDC, 2019). Show less	Infants and toddlers are particularly vulnerable to infectious diseases because their immune systems have not built up the necessary defenses to fight infection (HHS-OIDP, 2022). One study estimated that routine childhood vaccines administered in 2019 prevented 24 million diseases... (Talbird et al., 2022). Another recent study estimated that routine childhood vaccinations prevented 17.8 million cases of disease and 31,000 deaths for children born in 2017, in addition to saving $13.7 billion in health care costs (Carrico et al., 2022). Immunizing a child not only protects that child's health but also the health of the community, especially for those who are not immunized or are unable to be immunized due to other health complications (HHS-OIDP, 2022). Show more > Infants and toddlers are particularly vulnerable to infectious diseases because their immune systems have not built up the necessary defenses to fight infection (HHS-OIDP, 2022). One study estimated that routine childhood vaccines administered in 2019 prevented 24 million diseases (Talbird et al., 2022). Another recent study estimated that routine childhood vaccinations prevented 17.8 million cases of disease and 31,000 deaths for children born in 2017, in addition to saving $13.7 billion in health care costs (Carrico et al., 2022). Immunizing a child not only protects that child's health but also the health of the community, especially for those who are not immunized or are unable to be immunized due to other health complications (HHS-OIDP, 2022). Show less
Clinical Recommendation Statement	*See CMS117v11.html	This measure looks for childhood vaccinations that should be completed by age 2, in accordance with the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (CDC ACIP) recommended child and adolescent immunization schedule (CDC ACIP, 2022). -- For the... 2022–23 season, see the 2022–23 ACIP influenza vaccine recommendations (Grohskopf, 2022). Show more > This measure looks for childhood vaccinations that should be completed by age 2, in accordance with the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (CDC ACIP) recommended child and adolescent immunization schedule (CDC ACIP, 2022). -- For the 2022–23 season, see the 2022–23 ACIP influenza vaccine recommendations (Grohskopf, 2022). Show less	This measure looks for childhood vaccinations that should be completed by age 2, in accordance with the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (CDC ACIP) recommended child and adolescent immunization schedule (CDC, 2023). -- For the 2023–24... season, see the 2023–24 ACIP influenza vaccine recommendations (Grohskopf, 2023). Show more > This measure looks for childhood vaccinations that should be completed by age 2, in accordance with the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (CDC ACIP) recommended child and adolescent immunization schedule (CDC, 2023). -- For the 2023–24 season, see the 2023–24 ACIP influenza vaccine recommendations (Grohskopf, 2023). Show less
Improvement Notation	Higher score indicates better quality	Higher score indicates better quality	Higher score indicates better quality
Definition	*See CMS117v11.html	Recommended vaccines: Vaccines and the schedule of vaccines as recommended by the ACIP for children two years of age. The measure may differ slightly from the ACIP recommendations because the measure focuses on immunizations that are appropriate by age 2. Also, there may be small... differences when there are shortages for a particular vaccine. Show more > Recommended vaccines: Vaccines and the schedule of vaccines as recommended by the ACIP for children two years of age. The measure may differ slightly from the ACIP recommendations because the measure focuses on immunizations that are appropriate by age 2. Also, there may be small differences when there are shortages for a particular vaccine. Show less	Recommended vaccines: Vaccines and the schedule of vaccines as recommended by the ACIP for children two years of age. The measure may differ slightly from the ACIP recommendations because the measure focuses on immunizations that are appropriate by age 2. Also, there may be small... differences when there are shortages for a particular vaccine. Show more > Recommended vaccines: Vaccines and the schedule of vaccines as recommended by the ACIP for children two years of age. The measure may differ slightly from the ACIP recommendations because the measure focuses on immunizations that are appropriate by age 2. Also, there may be small differences when there are shortages for a particular vaccine. Show less
Guidance	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.	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.	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.
Initial Population	Children who turn 2 years of age during the measurement period and 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	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 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. Show more > 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. Show less	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. Show more > 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. Show less	Exclude children 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 - Human Immunodeficiency Virus (HIV) - Lymphoreticular cancer, multiple... myeloma or leukemia - Intussusception Show more > Exclude children 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 - Human Immunodeficiency Virus (HIV) - Lymphoreticular cancer, multiple myeloma or leukemia - Intussusception Show less
Numerator	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. Show more > 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. Show less	DTaP 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. IPV Children with either of the following on or before the child’s second birthday meet criteria: - At least three IPV vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth. - Anaphylaxis due to the IPV vaccine. MMR Children with any of the following meet criteria: - At least one MMR vaccination on or between the child’s first and second birthdays. - Anaphylaxis due to the MMR vaccine on or before the child’s second birthday. - All of the following anytime on or before the child’s second birthday (on the same or different date of service): - History of measles. - History of mumps. - History of rubella. 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. Hep 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. - 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. VZV Children with any 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. - Anaphylaxis due to the VZV vaccine on or before the child’s second birthday. - History of varicella zoster (e.g., chicken pox) illness on or before the child’s second birthday. PCV Children with either of the following on or before the child’s second birthday meet criteria: - 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. - Anaphylaxis due to the pneumococcal vaccine. Hep A Children with any 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. - Anaphylaxis due to the hepatitis A vaccine on or before the child’s second birthday. - History of hepatitis A illness on or before the child’s second birthday. RV 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. Flu Children with either of the following on or before their second birthday meet criteria: - 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 a Live Attenuated Influenza Vaccine (LAIV) vaccination administered on the child’s second birthday. Do not count a LAIV vaccination administered before the child’s second birthday. - Anaphylaxis due to the influenza vaccine. Show more > DTaP 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. IPV Children with either of the following on or before the child’s second birthday meet criteria: - At least three IPV vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth. - Anaphylaxis due to the IPV vaccine. MMR Children with any of the following meet criteria: - At least one MMR vaccination on or between the child’s first and second birthdays. - Anaphylaxis due to the MMR vaccine on or before the child’s second birthday. - All of the following anytime on or before the child’s second birthday (on the same or different date of service): - History of measles. - History of mumps. - History of rubella. 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. Hep 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. - 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. VZV Children with any 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. - Anaphylaxis due to the VZV vaccine on or before the child’s second birthday. - History of varicella zoster (e.g., chicken pox) illness on or before the child’s second birthday. PCV Children with either of the following on or before the child’s second birthday meet criteria: - 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. - Anaphylaxis due to the pneumococcal vaccine. Hep A Children with any 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. - Anaphylaxis due to the hepatitis A vaccine on or before the child’s second birthday. - History of hepatitis A illness on or before the child’s second birthday. RV 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. Flu Children with either of the following on or before their second birthday meet criteria: - 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 a Live Attenuated Influenza Vaccine (LAIV) vaccination administered on the child’s second birthday. Do not count a LAIV vaccination administered before the child’s second birthday. - Anaphylaxis due to the influenza vaccine. Show less	DTaP 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. IPV Children with either of the following on or before the child’s second birthday meet criteria: - At least three IPV vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth. - Anaphylaxis due to the IPV vaccine. MMR Children with any of the following meet criteria: - At least one MMR vaccination on or between the child’s first and second birthdays. - Anaphylaxis due to the MMR vaccine on or before the child’s second birthday. - All of the following anytime on or before the child’s second birthday (on the same or different date of service): - History of measles. - History of mumps. - History of rubella. 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. HepB 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. - 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. VZV Children with any 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. - Anaphylaxis due to the VZV vaccine on or before the child’s second birthday. - History of varicella zoster (e.g., chicken pox) illness on or before the child’s second birthday. PCV Children with either of the following on or before the child’s second birthday meet criteria: - 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. - Anaphylaxis due to the pneumococcal vaccine. HepA Children with any 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. - Anaphylaxis due to the hepatitis A vaccine on or before the child’s second birthday. - History of hepatitis A illness on or before the child’s second birthday. RV 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. Flu Children with either of the following on or before their second birthday meet criteria: - 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 a Live Attenuated Influenza Vaccine (LAIV) vaccination administered on the child’s second birthday. Do not count a LAIV vaccination administered before the child’s second birthday. - Anaphylaxis due to the influenza vaccine. Show more > DTaP 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. IPV Children with either of the following on or before the child’s second birthday meet criteria: - At least three IPV vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth. - Anaphylaxis due to the IPV vaccine. MMR Children with any of the following meet criteria: - At least one MMR vaccination on or between the child’s first and second birthdays. - Anaphylaxis due to the MMR vaccine on or before the child’s second birthday. - All of the following anytime on or before the child’s second birthday (on the same or different date of service): - History of measles. - History of mumps. - History of rubella. 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. HepB 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. - 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. VZV Children with any 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. - Anaphylaxis due to the VZV vaccine on or before the child’s second birthday. - History of varicella zoster (e.g., chicken pox) illness on or before the child’s second birthday. PCV Children with either of the following on or before the child’s second birthday meet criteria: - 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. - Anaphylaxis due to the pneumococcal vaccine. HepA Children with any 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. - Anaphylaxis due to the hepatitis A vaccine on or before the child’s second birthday. - History of hepatitis A illness on or before the child’s second birthday. RV 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. Flu Children with either of the following on or before their second birthday meet criteria: - 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 a Live Attenuated Influenza Vaccine (LAIV) vaccination administered on the child’s second birthday. Do not count a LAIV vaccination administered before the child’s second birthday. - Anaphylaxis due to the influenza vaccine. Show less
Numerator Exclusions	Not Applicable	Not Applicable	Not Applicable
Denominator Exceptions	None	None	None
Telehealth Eligible	Yes	Yes	Yes
Next Version	CMS117v12	CMS117v13	No Version Available
Previous Version	No Version Available	CMS117v11	CMS117v12

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Specifications

There is a known issue on CMS117v11. See issue EKI-27 on the ONC eCQM Known Issues Dashboard for details.

Additional Resources for CMS117v11

CMS117v11-TRN.xlsx

Header

Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
Updated references.
Measure Section: Reference
Source of Change: Measure Lead
Removed language related to adverse reactions from the guidance to align with the measure intent.
Measure Section: Guidance
Source of Change: Measure Lead
Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.
Measure Section: Guidance
Source of Change: Standards/Technical Update
Removed seropositive test results from the narrative because conducting antibody testing to determine immunity from a disease in lieu of vaccination is not specifically recommended by the CDC.
Measure Section: Numerator
Source of Change: Measure Lead
Relocated information regarding vaccination guidelines from the clinical recommendation statement to the numerator to improve clarity.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Relocated the numerator inclusion criteria from the guidance field to the denominator exclusions for children with severe combined immunodeficiency, immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma or leukemia, and intussusception before their second birthday.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Updated grammar and punctuation to improve readability.
Measure Section: Multiple Sections
Source of Change: Measure Lead

Logic

Updated the logic to replace the value set, 'Encephalopathy due to Childhood Vaccination' with 'Encephalitis Due to Diphtheria, Tetanus or Pertussis Vaccine' to align with the measure intent.
Measure Section: Definitions
Source of Change: Measure Lead
Revised the logic timing requirement for the Hepatitis A, MMR, and VZV vaccination to align with the intent of the measure and CDC recommendations.
Measure Section: Definitions
Source of Change: Measure Lead
Removed the Anaphylactic Reaction to Common Baker's Yeast value set from the logic to align with the measure intent.
Measure Section: Definitions
Source of Change: Measure Lead
Removed seropositive test results from the numerator logic because conducting antibody testing to determine immunity from a disease in lieu of vaccination is not specifically recommended by the CDC.
Measure Section: Definitions
Source of Change: Measure Lead
Added QDM datatypes 'Encounter, Performed' and 'Assessment, Performed' and associated logic to the Hospice.'Has Hospice Services' definition to provide additional approaches for identifying patients receiving hospice services.
Measure Section: Definitions
Source of Change: Measure Lead
Updated the logic to add the 'NormalizeInterval' function to additional QDM datatypes to decrease implementation burden due to variable use of timing attributes.
Measure Section: Definitions
Source of Change: Measure Lead
Updated the version number of the Hospice Library to v4.0.000.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Relocated the numerator inclusion criteria logic to the denominator exclusions logic for children with severe combined immunodeficiency, immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma or leukemia, and intussusception before their second birthday.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Updated the logic to align with the numerator requirement for the Hepatitis B vaccine criteria.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Updated the timing precision in the definitions from datetime to date by adding 'day of', 'date from', and/or function 'ToDateInterval' to align with the measure intent.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.
Measure Section: Multiple Sections
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: Multiple Sections
Source of Change: Standards/Technical Update
Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Updated the logic to remove adverse reaction criteria related to vaccines to align with the intent of the measure.
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 Inactivated Polio Vaccine (IPV) (2.16.840.1.113883.3.464.1003.196.12.1219): Added 1 CVX code (146) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Severe Combined Immunodeficiency (2.16.840.1.113883.3.464.1003.120.12.1007): Added 8 SNOMED CT codes (763623001, 765188009, 783617001, 789777007, 765145001, 771517009, 782751003, 987840791000119102) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Inactivated Polio Vaccine (IPV) Administered (2.16.840.1.113883.3.464.1003.110.12.1045): Added 1 SNOMED CT code (16290681000119103) based on review by technical experts, SMEs, and/or public feedback. Added 1 CPT code (90697) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Influenza Vaccine (2.16.840.1.113883.3.464.1003.196.12.1218): Added 2 CVX codes (171, 186) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 CVX code (135) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Influenza Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1044): Added 2 CPT codes (90674, 90756) based on review by technical experts, SMEs, and/or public feedback. Added 1 SNOMED CT code (786847005) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Malignant Neoplasm of Lymphatic and Hematopoietic Tissue (2.16.840.1.113883.3.464.1003.108.12.1009): Added 28 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 16 SNOMED CT codes based on validity of code during timing of look back period. Added 1 ICD-10-CM code (C84.7A) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 ICD-10-CM code (C96.2) based on validity of code during timing of look back period.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Measles (2.16.840.1.113883.3.464.1003.110.12.1053): Added 2 SNOMED CT codes (417145006, 424306000) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Pneumococcal Conjugate Vaccine (2.16.840.1.113883.3.464.1003.196.12.1221): Added 1 CVX code (109) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Varicella Zoster (2.16.840.1.113883.3.464.1003.110.12.1039): Added 8 SNOMED CT codes (1087131000119102, 15678841000119100, 15680281000119103, 15991751000119109, 15992351000119104, 16000751000119105, 16000791000119100, 16000831000119106) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed direct reference code SNOMED CT code (292927007) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Hib Vaccine (4 dose schedule) Administered (2.16.840.1.113883.3.464.1003.110.12.1086): Deleted 6 SNOMED CT codes (127787002, 170343007, 170344001, 170345000, 170346004, 312869001) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 CPT code (90748) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed direct reference code SNOMED CT code (292925004) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed direct reference code SNOMED CT code (292992006) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed direct reference code SNOMED CT code (293116002) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed direct reference code SNOMED CT code (293117006) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed direct reference code SNOMED CT code (293126009) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed direct reference code SNOMED CT code (420113004) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Hib Vaccine (4 dose schedule) (2.16.840.1.113883.3.464.1003.110.12.1085): Added 1 CVX code (146) based on review by technical experts, SMEs, and/or public feedback. Deleted 2 CVX codes (50, 51) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Anaphylactic Reaction to DTaP Vaccine (2.16.840.1.113883.3.464.1003.199.12.1031): Deleted 2 SNOMED CT codes (219084006, 293108006) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Hib Vaccine (3 dose schedule) Administered (2.16.840.1.113883.3.464.1003.110.12.1084): Added 2 CPT codes (90697, 90748) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set Mumps Antibody Test (IgG Antibody presence) (2.16.840.1.113883.3.464.1003.198.12.1062) based on change in measure requirements/measure specification.
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 1 CPT code (90697) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Replaced value set Hospice Care Ambulatory (2.16.840.1.113762.1.4.1108.15) with value set Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Replaced value set Encephalopathy due to Childhood Vaccination (2.16.840.1.113883.3.464.1003.114.12.1007) with value set Encephalitis Due to Diphtheria, Tetanus or Pertussis Vaccine (2.16.840.1.113883.3.464.1003.1164) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Hospice Encounter (2.16.840.1.113883.3.464.1003.1003) 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 Common Baker's Yeast (2.16.840.1.113883.3.464.1003.199.12.1032) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set Anti Hepatitis A IgG Antigen Test (2.16.840.1.113883.3.464.1003.198.12.1033) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set Anti Hepatitis B Virus Surface Ab (2.16.840.1.113883.3.464.1003.198.12.1073) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set Measles Antibody Test (IgG Antibody Titer) (2.16.840.1.113883.3.464.1003.198.12.1059) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set Measles Antibody Test (IgG Antibody presence) (2.16.840.1.113883.3.464.1003.198.12.1060) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set Mumps Antibody Test (IgG Antibody Titer) (2.16.840.1.113883.3.464.1003.198.12.1061) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Hib Vaccine (3 dose schedule) (2.16.840.1.113883.3.464.1003.110.12.1083): Added 2 CVX codes (17, 51) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added direct reference code LOINC code (45755-6) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set Rubella Antibody Test (IgG Antibody Titer) (2.16.840.1.113883.3.464.1003.198.12.1063) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set Rubella Antibody Test (IgG Antibody presence) (2.16.840.1.113883.3.464.1003.198.12.1064) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set Varicella Zoster Antibody Test (IgG Antibody Presence) (2.16.840.1.113883.3.464.1003.198.12.1067) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set Varicella Zoster Antibody Test (IgG Antibody Titer) (2.16.840.1.113883.3.464.1003.198.12.1066) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead
Value set DTaP Vaccine (2.16.840.1.113883.3.464.1003.196.12.1214): Added 1 CVX code (146) based on review by technical experts, SMEs, and/or public feedback.
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 1 CPT code (90697) 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 4 SNOMED CT codes (724361001, 1144907001, 1144908006, 1144963000) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set HIV (2.16.840.1.113883.3.464.1003.120.12.1003): Added 13 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Added 6 ICD-10-CM codes (O98.711, O98.712, O98.713, O98.719, O98.72, O98.73) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Hepatitis B Vaccine (2.16.840.1.113883.3.464.1003.196.12.1216): Added 1 CVX code (146) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set Positive Finding (2.16.840.1.113883.3.464.1003.121.12.1016) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added direct reference code SNOMED CT code (373066001) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Measure Lead

Compare Versions of: "Childhood Immunization Status"

Additional Resources for CMS117v11

Header

Logic

Value set

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