Childhood Immunization Status
Compare Versions of: "Childhood Immunization Status"
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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... Show more > |
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... Show more > |
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...Show more > |
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... Show more > |
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- IntussusceptionExclude children who are in hospice care for any part of the measurement...Show more > |
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...Show more > |
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.
Additional Resources for CMS117v12
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