Back to top
Top

Childhood Immunization Status

General eCQM Information

CMS Measure ID CMS117v10
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 who are in hospice care for any part of 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 Type Process
Improvement Notation

Higher score equals better quality

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 (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Quality ID 240
Meaningful Measure Preventive Care
Telehealth Eligible Yes
Previous Version

Release Notes

Header

  • Updated the eCQM version number.

    Measure Section: eCQM Version Number

    Source of Change: Annual Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated the clinical recommendation statement to align with current clinical recommendations.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Annual Update

  • Revised the guidance to clarify the measure intent and numerator criteria.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Replaced 'overlaps' or 'overlapping' in the denominator exclusions with plain language to clarify the measure intent.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

Logic

  • Revised the initial population to remove lower age boundary.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Added definitions 'LAIV Vaccinations' and 'Two Influenza Vaccinations Including One LAIV Vaccination' to the numerator to to allow for patients 2 years of age to receive an influenza LAIV vaccination as one of the two recommended influenza immunization doses.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Replaced the 'Anaphylactive Reaction to Hepatitis A Vaccine' value set with a direct reference code 'Adverse reaction to vaccine product containing Hepatitis A virus antigen' in the Hepatitis A Numerator Inclusion Conditions definition.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated select numerator definitions with current SNOMED code descriptions.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.

    Measure Section: Functions

    Source of Change: Standards Update

  • Added the definition 'Date of Second Birthday' to clarify the timing for patient's second birthday for numerator criteria.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Added online assessments and telephone visits as appropriate encounters based on the increased use of telehealth services.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated Hospice CQL Library to version 3.0.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

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 Measles, Mumps and Rubella (MMR) Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1031): Added 2 SNOMED CT codes (571591000119106, 572511000119105) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Rubella (2.16.840.1.113883.3.464.1003.110.12.1037): Deleted 2 SNOMED CT codes (111867004, 84611003) based on validity of code during timing of look back period.

    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 3 SNOMED CT codes (871752004, 871753009, 871754003) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Inactivated Polio Vaccine (IPV) Administered (2.16.840.1.113883.3.464.1003.110.12.1045): Added 21 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 (2.16.840.1.113883.3.464.1003.110.12.1053): Added 1 SNOMED CT code (359686005) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Removed value set Anaphylactic Reaction to Hepatitis A Vaccine (2.16.840.1.113883.3.464.1003.199.12.1026) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Hepatitis B (2.16.840.1.113883.3.464.1003.110.12.1025): Added 1 SNOMED CT code (838380002) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Malignant Neoplasm of Lymphatic and Hematopoietic Tissue (2.16.840.1.113883.3.464.1003.108.12.1009): Added 61 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 28 SNOMED CT codes based on validity of code during timing of look back period.

    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 13 SNOMED CT codes 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 12 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 2 SNOMED CT codes (234603007, 25109007) based on review by technical experts, SMEs, and/or public feedback. Added 10 ICD-10-CM codes (D84.81, D84.821, D84.822, D84.89, D89.831, D89.832, D89.833, D89.834, D89.835, D89.839) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Severe Combined Immunodeficiency (2.16.840.1.113883.3.464.1003.120.12.1007): Deleted 1 SNOMED CT code (203592006) based on validity of code during timing of look back period.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Intussusception (2.16.840.1.113883.3.464.1003.199.12.1056): Added 3 SNOMED CT codes (26316005, 64976006, 91446004) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 SNOMED CT code (197048002) based on validity of code during timing of look back period.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Varicella Zoster (2.16.840.1.113883.3.464.1003.110.12.1039): Added 11 SNOMED CT codes (15685201000119100, 15685281000119108, 15936581000119108, 15936621000119108, 15989271000119107, 15989311000119107, 15989351000119108, 15991711000119108, 15991791000119104, 838357005, 98541000119101) based on review by technical experts, SMEs, and/or public feedback. Deleted 3 SNOMED CT codes (15681321000119100, 15681401000119101, 186525007) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Hepatitis B Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1042): Added 6 SNOMED CT codes (572561000119108, 770608009, 770616000, 770618004, 786846001, 787438002) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 SNOMED CT code (116802006) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Influenza Virus LAIV Immunization (2.16.840.1.113883.3.464.1003.110.12.1087) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Influenza Virus LAIV Procedure (2.16.840.1.113883.3.464.1003.110.12.1088) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Online Assessment (2.16.840.1.113883.3.464.1003.101.12.1089) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set HIV (2.16.840.1.113883.3.464.1003.120.12.1003): Added 9 SNOMED codes (838377003, 840498003, 10755671000119100, 15928141000119107, 771119002, 771126002, 771127006, 72631000119101, 840442003) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Added direct reference code CPT code (99211) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jul 08, 2021