Childhood Immunization Status
Compare Versions of: "Childhood Immunization Status"
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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 |
| 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 |
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 |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process measure | Process measure | Process measure |
| Stratification | *See CMS117v10.html | *See CMS117v11.html |
None |
| Risk Adjustment | *See CMS117v10.html | *See CMS117v11.html |
None |
| Rationale | *See CMS117v10.html | *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). |
| Clinical Recommendation Statement | *See CMS117v10.html | *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). |
| Improvement Notation |
Higher score equals better quality |
Higher score indicates better quality |
Higher score indicates better quality |
| Definition | *See CMS117v10.html | *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. |
| 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. |
| 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 |
| Telehealth Eligible | Yes | Yes | Yes |
| Next Version | No Version Available | ||
| Previous Version | No Version Available |
*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