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

Additional Resources for CMS117v13

CMS117v13-TRN.xlsx

Header

Updated the eCQM version number.
Measure Section:
eCQM Version Number
Source of Change:
Annual Update
Changed all references from NQF to CBE to identify the consensus-based entity role.
Measure Section:
CBE Number
Source of Change:
Annual Update
Updated the acronyms for hepatitis B and hepatitis A to align with CDC's naming conventions for the vaccines.
Measure Section:
Description
Source of Change:
Measure Lead
Updated copyright.
Measure Section:
Copyright
Source of Change:
Annual Update
Aligned order of exclusions listed in the narrative and logic to improve readability.
Measure Section:
Denominator Exclusions
Source of Change:
Measure Lead
Updated the acronyms for hepatitis B and hepatitis A to align with CDC's naming conventions for the vaccines.
Measure Section:
Numerator
Source of Change:
Measure Lead
Updated grammar, wording, and/or formatting to improve readability and consistency.
Measure Section:
Multiple Sections
Source of Change:
Annual Update
Updated references and measure header to reflect current evidence and new or updated literature.
Measure Section:
Multiple Sections
Source of Change:
Measure Lead

Logic

Renamed value set to 'Payer Type' to more accurately reflect the contents and intent of the value set.
Measure Section:
Definitions
Source of Change:
Standards/Technical Update
Consolidated and updated the logic to incorporate the use of 'date from' and the use of the 'EarliestOf' function that returns a starting point of a period if specified, otherwise will return the ending point, to more precisely confirm immunizations captured to occur on different days.
Measure Section:
Definitions
Source of Change:
ONC Project Tracking System (JIRA): CQM-6169
Updated the timing comparison precision in the definitions from datetime to date by adding 'day of' operator to align with the measure intent and address time zone issues.
Measure Section:
Definitions
Source of Change:
Measure Lead
Updated the value set name for 'Online Assessments' to 'Virtual Encounter' for a more accurate description.
Measure Section:
Definitions
Source of Change:
Measure Lead
Updated the version number of the Hospice Library to v6.0.000 and the library name from 'Hospice' to 'HospiceQDM.'
Measure Section:
Definitions
Source of Change:
Annual Update
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'
Measure Section:
Definitions
Source of Change:
Annual Update
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'
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.

Removed ICD-9 extensional value sets from select grouping value sets, leaving codes from active terminologies (ICD-10 and SNOMED), to reduce implementer burden.
Measure Section:
Terminology
Source of Change:
Standards/Technical Update
Value set (2.16.840.1.113883.3.464.1003.196.12.1218): Renamed to Child Influenza Vaccine 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 3 SNOMED CT codes (65880007, 1268379007, 1279887007) based on review by technical experts, SMEs, and/or public feedback. Deleted 3 SNOMED CT codes (234603007, 25109007, 234416002) based on review by technical experts, SMEs, and/or public feedback. Added 1 ICD-10-CM code (D89.84) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 ICD-10-CM code (D84.8) 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 SNOMED CT code (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): Added 1 SNOMED CT code (571511000119102) 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 2 SNOMED CT codes (1187000005, 1260096003) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 SNOMED CT code (420687005) based on review by technical experts, SMEs, and/or public feedback. Deleted 3 ICD-9-CM codes (042, 079.53, V08) based on applicability of value set and/or OID.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Home Healthcare Services (2.16.840.1.113883.3.464.1003.101.12.1016): Deleted 1 CPT code (99343) 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): Added 2 SNOMED CT codes (170935008, 170936009) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 SNOMED CT code (385765002) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set (2.16.840.1.113883.3.464.1003.110.12.1087): Renamed to Influenza Virus LAIV Vaccine based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set (2.16.840.1.113883.3.464.1003.110.12.1088): Renamed to Influenza Virus LAIV Vaccine Administered 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 86 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 133 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001): Deleted 2 SNOMED CT codes (30346009, 37894004) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 CPT code (99201) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Virtual Encounter (2.16.840.1.113883.3.464.1003.101.12.1089): Deleted 2 CPT codes (98969, 99444) based on review by technical experts, SMEs, and/or public feedback. Deleted 3 HCPCS codes (G2061, G2062, G2063) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set (2.16.840.1.114222.4.11.3591): Renamed to Payer Type based on recommended value set naming conventions.
Measure Section:
Terminology
Source of Change:
Annual Update
Value set Pneumococcal Conjugate Vaccine (2.16.840.1.113883.3.464.1003.196.12.1221): Added 1 CVX code (216) 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 4 SNOMED CT codes (1119366009, 12866006, 394678003, 871833000) based on review by technical experts, SMEs, and/or public feedback. Added 1 CPT code (90677) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set (2.16.840.1.113883.3.464.1003.101.12.1089): Renamed to Virtual Encounter based on recommended value set naming conventions.
Measure Section:
Terminology
Source of Change:
Annual Update

Compare Versions of: "Childhood Immunization Status"

Additional Resources for CMS117v13

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Logic

Value Set

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