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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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Measure Information 2022 Performance Period 2023 Performance Period 2024 Performance Period
Title Childhood Immunization Status Childhood Immunization Status Childhood Immunization Status
CMS eCQM ID CMS117v10 CMS117v11 CMS117v12
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 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 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.

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

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.

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.

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 indicates better quality

Higher score indicates 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.

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.

MIPS Quality ID 240 240 240
Telehealth Eligible Yes Yes Yes
Notes

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

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

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

Next Version No Version Available
Previous Version No Version Available

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: Feb 14, 2024