Childhood Immunization Status

Last updated: July 12, 2017

CMS Measure ID: CMS117v3
Version: 3
NQF Number: 0038
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 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 Patient 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 Patient Population

Denominator Exclusions:

None

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 and Public Health
Next Version: Childhood Immunization Status
Measure Score: Proportion
Score Type: Process
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 conjugate, rotavirus, and influenza vaccines, numerator inclusion criteria include only evidence of receipt of the recommended vaccine. Patients may be excepted from a particular antigen if they had an anaphylactic reaction to the vaccine. Patients may be excepted from the DTaP vaccine if they have encephalopathy. Patients may be excepted from the IPV vaccine if they have had an anaphylactic reaction to streptomycin, polymyxin B, or neomycin. Patients may be excepted from the influenza vaccines if they have cancer of lymphoreticular or histiocytic tissue, multiple myeloma, leukemia, or have had an anaphylactic reaction to neomycin. Patients may be excepted from the MMR or VZV vaccines if they have cancer of lymphoreticular or histiocytic tissue, multiple myeloma, leukemia, or have had an anaphylactic reaction to neomycin. Patients may be excepted from 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.

Specifications

External Resources