| Measure Information | 2021 Performance Period |
|---|---|
| CMS Measure ID | CMS117v9 |
| NQF Number | Not Applicable |
| Measure 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 |
| Initial Population | Children who turn 2 years of age during the measurement period and who have a visit during the measurement period |
| Denominator Statement |
Equals Initial Population |
| Denominator Exclusions |
Exclude patients whose hospice care overlaps the measurement period |
| Numerator Statement |
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 |
| Numerator Exclusions |
Not Applicable |
| Denominator Exceptions |
None |
| Measure Steward | National Committee for Quality Assurance |
| Domain | Community/Population Health |
| Measure Scoring | Proportion measure |
| Measure Type | Process measure |
| Improvement Notation |
Higher score equals better quality |
| Guidance |
For the MMR, hepatitis B, VZV and hepatitis A vaccines, numerator inclusion criteria include: evidence of receipt of the recommended vaccine; documented history of the illness; or, a seropositive test result for the antigen. For the DTaP, IPV, Hib, pneumococcal, rotavirus, and influenza vaccines, numerator inclusion criteria include only evidence of receipt of the recommended vaccine. Patients may be included in the numerator for a particular antigen if they had an anaphylactic reaction to the vaccine. Patients may be included in the numerator for the DTaP vaccine if they have encephalopathy. Patients may be included in the numerator for the IPV vaccine if they have had an anaphylactic reaction to streptomycin, polymyxin B, or neomycin. Patients may be included in the numerator for the influenza, MMR, or varicella vaccines if they have cancer of lymphoreticular or histiocytic tissue, multiple myeloma, leukemia, have had an anaphylactic reaction to neomycin, have immunodeficiency, or have HIV. Patients may be included in the numerator for the hepatitis B vaccine if they have had an anaphylactic reaction to common baker's yeast. 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. |
| MIPS Quality ID | 240 |
| Meaningful Measure | Preventive Care |
| Telehealth Eligible | Yes |
| Next Version | |
| Previous Version |
Data Element Repository
Header
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Updated eCQM Version Number.
Measure Section: eCQM Version Number
Source of Change: Standards Update
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Revised to use 'Hib' instead of 'HiB' abbreviation to improve consistency and accuracy.
Measure Section: Description
Source of Change: Measure Lead
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Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Updated the Rationale to remove outdated references and content and to update references.
Measure Section: Rationale
Source of Change: Measure Lead
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Revised to use 'Hib' instead of 'HiB' abbreviation to improve consistency and accuracy.
Measure Section: Clinical Recommendation Statement
Source of Change: Measure Lead
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Updated the Clinical Recommendations Statement to remove outdated references and update with the most recent clinical recommendations.
Measure Section: Clinical Recommendation Statement
Source of Change: Measure Lead
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Updated references.
Measure Section: Reference
Source of Change: Standards Update
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Updated the guidance to remove 'conjugate' and 'VZV' and add 'Varicella' for additional clarification.
Measure Section: Guidance
Source of Change: Measure Lead
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Added text to identify the Quality Data Model (QDM) version used in the measure specification.
Measure Section: Guidance
Source of Change: Standards Update
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Added text to indicate whether the measure is patient-based or episode-based.
Measure Section: Guidance
Source of Change: Standards Update
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Revised to use 'Hib' instead of 'HiB' abbreviation to improve consistency and accuracy.
Measure Section: Guidance
Source of Change: Measure Lead
Logic
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Revised to use 'Hib' instead of 'HiB' abbreviation to improve consistency and accuracy.
Measure Section: Numerator
Source of Change: Measure Lead
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Revised to use 'Hib' instead of 'HiB' abbreviation to improve consistency and accuracy.
Measure Section: Definitions
Source of Change: Measure Lead
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Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section: Definitions
Source of Change: Standards Update
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Updated timing logic for the follow-up assessment to use 'in Interval' to simplify logic and promote harmonization between measures.
Measure Section: Definitions
Source of Change: Measure Lead
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Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section: Functions
Source of Change: Standards Update
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CQL Library version update: Updated version number of the Hospice Library (Hospice-2.2.000).
Measure Section: Multiple Sections
Source of Change: Measure Lead
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QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Updated CQL expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).
Measure Section: Multiple Sections
Source of Change: Standards Update
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Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000). Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.
Measure Section: Multiple Sections
Source of Change: Standards 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.
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Value set HIV (2.16.840.1.113883.3.464.1003.120.12.1003): Deleted 15 SNOMED CT codes based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
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Value set (2.16.840.1.113883.3.464.1003.110.12.1083): Renamed to Hib Vaccine (3 dose schedule).
Measure Section: Terminology
Source of Change: Annual Update
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Value set (2.16.840.1.113883.3.464.1003.110.12.1084): Renamed to Hib Vaccine (3 dose schedule) Administered.
Measure Section: Terminology
Source of Change: Annual Update
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Value set (2.16.840.1.113883.3.464.1003.110.12.1085): Renamed to Hib Vaccine (4 dose schedule).
Measure Section: Terminology
Source of Change: Annual Update
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Value set (2.16.840.1.113883.3.464.1003.110.12.1086): Renamed to Hib Vaccine (4 dose schedule) Administered.
Measure Section: Terminology
Source of Change: Annual Update