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Childhood Immunization Status

Compare Versions of: "Childhood Immunization Status"

The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.

Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.

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Table Options
Measure Information 2024 Performance Period
Title Childhood Immunization Status
CMS eCQM ID CMS117v12
CBE ID* Not Applicable
MIPS Quality ID 240
Measure Steward 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...

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Measure Scoring Proportion measure
Measure Type Process
Stratification

None

Risk Adjustment

None

Rationale

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...

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Clinical Recommendation Statement

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...

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Improvement Notation

Higher score indicates better quality

Definition

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...

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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.

Initial Population

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

Denominator

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...

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Numerator

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...

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Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Telehealth Eligible Yes
Next Version
Previous Version

There is a known issue on CMS117v12. See issue EKI-27 on the ONC eCQM Known Issues Dashboard for details.

Header

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated the rationale based upon more recent literature and evidence to support the measure.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated the clinical recommendation statement based upon more recent literature and evidence to support the measure.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated grammar, wording, and/or formatting to improve readability and consistency.

    Measure Section: Denominator Exclusions

    Source of Change: Annual Update

  • Updated grammar, wording, and/or formatting to improve readability and consistency.

    Measure Section: Numerator

    Source of Change: Annual Update

  • Added anaphylaxis due to vaccine as a numerator criterion to align with the Advisory Committee on Immunization Practices (ACIP) recommendations.

    Measure Section: Numerator

    Source of Change: Measure Lead

Logic

  • Added anaphylaxis due to vaccine as a numerator criterion to align with the Advisory Committee on Immunization Practices (ACIP) recommendations.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Updated the version number of the Hospice Library to v5.0.000.

    Measure Section: Definitions

    Source of Change: Annual Update

  • Updated the timing comparison precision in the definitions from datetime to date by adding 'ToDateInterval' function to align with the measure intent and address time zone issues.

    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: Definitions

    Source of Change: Standards/Technical Update

  • Added 'day of' specificity to hospice expressions for consistency.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added QDM datatype 'Diagnosis' to the Hospice.'Has Hospice Services' definition referencing a new value set containing SNOMED finding codes to provide an additional approach for identifying patients receiving hospice care.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated logic so that receipt of three hepatitis B vaccine series doses, or a newborn vaccine and two subsequent doses are acceptable, to better align with the Numerator description and guideline recommended vaccination schedule.

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (JIRA): CQM-5361

  • Added anaphylaxis due to vaccine as a numerator criterion to align with the Advisory Committee on Immunization Practices (ACIP) recommendations.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated the version number of the Hospice Library to v5.0.000.

    Measure Section: Functions

    Source of Change: Annual 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.

  • Added direct reference codes 1 ICD-10-PCS (3E0234Z) and 6 SNOMED CT codes (471141000124102, 471311000124103, 471321000124106, 471331000124109, 471341000124104, 471361000124100) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.464.1003.196.12.1218): Renamed to Child Influenza Immunization Administered based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.464.1003.110.12.1044): Renamed to Child Influenza Vaccine Administered based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Child Influenza Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1044): Added 1 CPT code (90689) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 CPT code (90662) based on review by technical experts, SMEs, and/or public feedback. Deleted 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 Disorders of the Immune System (2.16.840.1.113883.3.464.1003.120.12.1001): Added 1 ICD-10-CM code (D81.82) based on review by technical experts, SMEs, and/or public feedback. Added 7 SNOMED CT codes (1162263002, 1177120001, 1197361002, 1197362009, 234603007, 25109007, 762618008) 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 5 SNOMED CT codes (868273007, 868274001, 868276004, 868277008, 1162640003) based on review by technical experts, SMEs, and/or public feedback. Deleted 9 SNOMED CT codes (170395004, 170396003, 170397007, 170399005, 170400003, 170401004, 170402006, 787438002, 428251000124104) based on review by technical experts, SMEs, and/or public feedback.

    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): Deleted 4 SNOMED CT codes (313188000, 313189008, 412742005, 412743000) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Hepatitis B (2.16.840.1.113883.3.464.1003.110.12.1025) with value set Hepatitis B (2.16.840.1.113883.3.67.1.101.1.269) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Hepatitis B Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1042): Added 4 SNOMED CT codes (1162640003, 170374009, 170375005, 416923003) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 SNOMED CT code (787438002) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 ICD-9-CM code (99.55) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 ICD-10-PCS code (3E0234Z) 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 1 SNOMED CT code (1187001009) based on review by technical experts, SMEs, and/or public feedback. Deleted 3 SNOMED CT codes (72621000119104, 72631000119101, 442134007) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584): Deleted 3 SNOMED CT codes (170935008, 170936009, 305911006) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Hospice Diagnosis (2.16.840.1.113883.3.464.1003.1165) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Hospice Encounter (2.16.840.1.113883.3.464.1003.1003): Added 2 SNOMED CT codes (305911006, 385765002) 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): Deleted 1 SNOMED CT code (786846001) 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 56 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, Mumps and Rubella (MMR) Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1031): Added 3 SNOMED CT codes (871909005, 170431005, 170432003) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 SNOMED CT code (150971000119104) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Mumps (2.16.840.1.113883.3.464.1003.110.12.1032): Added 1 SNOMED CT code (1163539003) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Online Assessments (2.16.840.1.113883.3.464.1003.101.12.1089): Added 4 CPT codes (98980, 98981, 99444, 99457) based on review by technical experts, SMEs, and/or public feedback. Added 3 HCPCS codes (G2250, G2251, G2252) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 5 SOP codes (1111, 1112, 142, 344, 141) 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 (215) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Pneumococcal Conjugate Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1046): Added 1 SNOMED CT code (1119368005) based on review by technical experts, SMEs, and/or public feedback. Added 1 CPT code (90671) 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 4 SNOMED CT codes (1179284005, 1229940001, 1229941002, 1229942009) 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 5 SNOMED CT codes (1163465001, 1163483009, 1179456002, 15681321000119100, 15681401000119101) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Varicella Zoster Vaccine (VZV) Administered (2.16.840.1.113883.3.464.1003.110.12.1040): Added 7 SNOMED CT codes (432636005, 433733003, 572511000119105, 737081007, 871898007, 871899004, 871909005) based on review by technical experts, SMEs, and/or public feedback. Deleted 2 SNOMED CT codes (571611000119101, 473164004) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jun 03, 2024