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Childhood Immunization Status

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eCQMs for 2021 Performance Period

CMS2v10
CMS22v9
CMS50v9
CMS56v9
CMS66v9
CMS68v10
CMS69v9
CMS74v10
CMS75v9
CMS90v10
CMS117v9
CMS122v9
CMS124v9
CMS125v9
CMS127v9
CMS128v9
CMS129v10
CMS130v9
CMS131v9
CMS133v9
CMS134v9
CMS135v9
CMS136v10
CMS137v9
CMS138v9
CMS139v9
CMS142v9
CMS143v9
CMS144v9
CMS145v9
CMS146v9
CMS147v10
CMS149v9
CMS153v9
CMS154v9
CMS155v9
CMS156v9
CMS157v9
CMS159v9
CMS161v9
CMS165v9
CMS177v9
CMS249v3
CMS347v4
CMS349v3
CMS645v4
CMS771v2

General eCQM Information

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.
Quality ID 240
Meaningful Measure Preventive Care
Telehealth Eligible Yes
Next Version
CMS117v10
Previous Version
CMS117v8
Specifications
Attachment Size
CMS117v9.html 119.6 KB
CMS117v9.zip 147.66 KB
CMS117v9-TRN.xlsx 21.98 KB

Data Element Repository

Release Notes

CMS117v9-TRN.xlsx

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Revised to use 'Hib' instead of 'HiB' abbreviation to improve consistency and accuracy.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​Updated the Rationale to remove outdated references and content and to update references.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Revised to use 'Hib' instead of 'HiB' abbreviation to improve consistency and accuracy.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • 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

  • Updated references.

    Measure Section: Reference

    Source of Change: Standards Update

  • Updated the guidance to remove 'conjugate' and 'VZV' and add 'Varicella' for additional clarification.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Added text to identify the Quality Data Model (QDM) version used in the measure specification.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Added text to indicate whether the measure is patient-based or episode-based.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Revised to use 'Hib' instead of 'HiB' abbreviation to improve consistency and accuracy.

    Measure Section: Guidance

    Source of Change: Measure Lead

Logic

  • Revised to use 'Hib' instead of 'HiB' abbreviation to improve consistency and accuracy.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Revised to use 'Hib' instead of 'HiB' abbreviation to improve consistency and accuracy.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • 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

  • 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

  • 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

  • CQL Library version update: Updated version number of the Hospice Library (Hospice-2.2.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • 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

  • 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

  • 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.

  • 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

  • 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

  • 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

  • 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

  • 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

Last Updated: May 05, 2021