Childhood Immunization Status

Last updated: May 3, 2018

CMS Measure ID: CMS117v6
Version: 6
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 Populationinfo-icon

Denominator Exclusions:

Exclude patients who were in hospice care during the measurement year

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
Next Version:
Previous Version:
Improvement Notation:

Higher score equals better quality

Guidance:

For the MMR, hepatitis B, VZV and hepatitis A vaccines, numeratorinfo-icon 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 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 VZV vaccines if they have cancer of lymphoreticular or histiocytic tissue, multiple myeloma, leukemia, have had an anaphylactic reaction to neomycin, have Immunodefiency, 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.

Notes: Value Set content updated Sept 2017, TRNs updated Oct 2017

Specifications

Release Notes

Header

  • ​Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • ​Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​Updated Disclaimer.

    Measure Section: Disclaimer

    Source of Change: Measure Lead

  • Updated References.

    Measure Section: Reference

    Source of Change: Measure Lead

  • ​Updated the exclusion statement in the header to exclude patients in hospice care from the Denominatorinfo-icon. Measures that focus on screenings and procedures may not be appropriate or a priority for those who are at end of life (ie, on hospice).

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

Logic

  • Added new lines of logic to the Denominator Exclusions for all NCQA-stewarded measures (except CMS82) to ensure patients in hospice care are excluded from the Denominator.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Added 'HIV' and 'Disorders of the Immune System' as diagnosis options to satisfy the Numeratorinfo-icon criteria for Influenza vaccination.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Added 'Intussusception' and 'Severe Combined Immunodeficiency' as diagnosis options to satisfy the Numerator criteria for Rotavirus vaccination (dose 2 and dose 3 schedules).

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Created QDMinfo-icon variables for vaccinations to allow for a combination of immunizations and procedures to satisfy Numerator criteria. The new variables are $DTaPVaccine, $HIBVaccine, $InfluenzaVaccine, $IPVVaccine, $PneumococcalConjugateVaccine, $RotavirusVaccine3Dose, $HepatitisBVaccine, $RotavirusVaccine2Dose.

    Measure Section: Numerator

    Source of Change: JIRA (CQMinfo-icon-2223)

  • Replaced the 'starts before start of' and 'starts before end of' logical operator to address situations where time stamps are not attached to procedures, diagnosis, and immunizations. Wherever applicable, the operators have been changed to 'starts before or concurrent with start of' or 'starts before or concurrent with end of' respectively.

    Measure Section: Numerator

    Source of Change: JIRA (CQM-1936)

  • Updated the Numerator logic for Hepatitis A and Hepatitis B vaccinations by clarifying the laboratory test and results that indicate a patient is seropositive for Hepatitis A or B.

    Measure Section: Numerator

    Source of Change: Measure Lead

Value Setinfo-icon

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value setsinfo-icon.

  • Value set Intussusception (2.16.840.1.113883.3.464.1003.199.12.1056): New value set with 1 ICD10CM and 19 SNOMED codes.

    Measure Section: QDM Data Elements

    Source of Change: Measure Lead

  • Value set Hepatitis A (2.16.840.1.113883.3.464.1003.110.12.1024): Deleted 2 ICD9CM codes (070.0, 070.1).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Mumps (2.16.840.1.113883.3.464.1003.110.12.1032): Deleted 9 ICD9CM codes (072.0, 072.1, 072.2, 072.3, 072.71, 072.72, 072.79, 072.8, 072.9). Added 1 SNOMEDCT code (89231008).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Rubella (2.16.840.1.113883.3.464.1003.110.12.1037): Deleted 7 ICD9CM codes (056.00, 056.01, 056.09, 056.71, 056.79, 056.8, 056.9). Added 5 SNOMEDCT codes (1092351000119107, 1092361000119109, 128191000, 192689006, 302811004).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Varicella Zoster (2.16.840.1.113883.3.464.1003.110.12.1039): Deleted 21 ICD9CM codes. Added 6 SNOMEDCT codes (15678761000119105, 15678801000119102, 713250002, 713733003, 713964006, 715223009).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Influenza Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1044): Added 1 CPT code (90687).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Measles (2.16.840.1.113883.3.464.1003.110.12.1053): Deleted 7 ICD9CM codes (055.0, 055.1, 055.2, 055.71, 055.79, 055.8, 055.9).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Encephalopathy due to Childhood Vaccination (2.16.840.1.113883.3.464.1003.114.12.1007): Deleted 1 ICD9CM code (323.51).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Hepatitis A Vaccine (2.16.840.1.113883.3.464.1003.196.12.1215): Deleted 1 CVX code (104) and added 1 CVX code (85).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Haemophilus Influenzae Type B (HiB) Vaccine (2.16.840.1.113883.3.464.1003.196.12.1217): Added 4 CVX codes (46, 47, 148, 17).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Inactivated Polio Vaccine (IPV) (2.16.840.1.113883.3.464.1003.196.12.1219): Added 2 CVX codes (120, 89) and deleted 1 CVX code (130).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Hepatitis A Antigen Test (2.16.840.1.113883.3.464.1003.198.12.1033): Renamed Hepatitis A Antigen Test to Anti Hepatitis A IgG Antigen Test.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Anti Hepatitis A IgG Antigen Test (2.16.840.1.113883.3.464.1003.198.12.1033): Added 3 LOINC codes (32018-4, 40724-7, 51913-2) and deleted 6 LOINC codes (22312-3, 22313-1, 22315-6, 5179-7, 5181-3, 5183-9).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Hepatitis B (2.16.840.1.113883.3.464.1003.110.12.1025): Deleted 1 SNOMEDCT code (424460009). Deleted 9 ICD9CM codes (070.20, 070.21, 070.22, 070.23, 070.30, 070.31, 070.32, 070.33, V02.61).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set DTaP Vaccine (2.16.840.1.113883.3.464.1003.196.12.1214): Deleted 1 CVX code (130).

    Measure Section: QDM Data Elements

    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): Deleted 301 ICD9CM codes. Added 28 SNOMEDCT codes. Added 39 ICD10CM codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set DTaP Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1022): Added 17 SNOMEDCT codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Haemophilus Influenzae Type B (HiB) Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1043): Added 1 CPT code (90644).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Disorders of the Immune System (2.16.840.1.113883.3.464.1003.120.12.1001): Deleted 23 ICD9CM codes. Added 8 SNOMEDCT codes (12631000119106, 713530002, 715982006, 716378008, 716871006, 718107000, 718230004, 718232007).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Encounter Inpatient (2.16.840.1.113883.3.666.5.307): Added Encounter Inpatient.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Hospice care ambulatory (2.16.840.1.113762.1.4.1108.15): Added Hospice care ambulatory.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Discharged to Health Care Facility for Hospice Care (2.16.840.1.113883.3.117.1.7.1.207): Added Discharged to Health Care Facility for Hospice Care.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Discharged to Home for Hospice Care (2.16.840.1.113883.3.117.1.7.1.209): Added Discharged to Home for Hospice Care.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Severe Combined Immunodeficiency (2.16.840.1.113883.3.464.1003.120.12.1007): Added Severe Combined Immunodeficiency.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Replaced value set Hepatitis B Antigen Test (2.16.840.1.113883.3.464.1003.198.12.1031) with Anti-Hepatitis B Virus Surface Ab (2.16.840.1.113883.3.464.1003.198.12.1073).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Seropositive (2.16.840.1.113883.3.464.1003.110.12.1054): Removed Seropositive.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Influenza Vaccine (2.16.840.1.113883.3.464.1003.196.12.1218): Added 2 CVX codes (158, 88).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Pneumococcal Conjugate Vaccine (2.16.840.1.113883.3.464.1003.196.12.1221): Deleted 1 CVX code (33).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Hepatitis B Vaccine (2.16.840.1.113883.3.464.1003.196.12.1216): Added 1 CVX code (45) and deleted 1 CVX code (104).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set HIV (2.16.840.1.113883.3.464.1003.120.12.1003): Added 70 SNOMEDCT codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Varicella Zoster Vaccine (VZV) Administered (2.16.840.1.113883.3.464.1003.110.12.1040): Added 1 SNOMEDCT code (571611000119101).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

  • Value set Malignant Neoplasm of Lymphatic and Hematopoietic Tissue (2.16.840.1.113883.3.464.1003.108.12.1009): Added 21 SNOMEDCT codes and deleted 3 SNOMEDCT codes (188651007, 421835000, 422052002). Added 4 ICD10CM codes (C96.20, C96.21, C96.22, C96.29).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

  • Value set Disorders of the Immune System (2.16.840.1.113883.3.464.1003.120.12.1001): Added 22 SNOMEDCT codes and deleted 2 SNOMEDCT codes (359791000, 77070006).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

  • Value set Severe Combined Immunodeficiency (2.16.840.1.113883.3.464.1003.120.12.1007): Added 5 SNOMEDCT codes (720345008, 720853005, 720986005, 721977007, 722067005).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

  • Value set Varicella Zoster (2.16.840.1.113883.3.464.1003.110.12.1039): Added 9 SNOMEDCT codes (12551000132107, 12571000132104, 15680201000119106, 15680241000119108, 15681321000119100, 15681401000119101, 15685081000119102, 15685121000119100, 723109003).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

External Resources