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Childhood Immunization Status

Last updated: September 14, 2018

CMS Measure ID: CMS117v7
Version: 7
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 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
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.

Quality ID: 240
Meaningful Measure: Preventive Care

Specifications

Release Notes

Header

  • Updated Version Number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated measure header rationale to align with most recent literature.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated clinical recommendation statement to align with current recommendations.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated header references to align with updated rationale and clinical recommendation statement.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Corrected misspelling of organization name in header definition.

    Measure Section: Definition

    Source of Change: Measure Lead

  • Updated the Denominator Exclusioninfo-icon statement for patients in hospice care to better align with the logic.

    Measure Section: Denominator Exclusionsinfo-icon

    Source of Change: JIRAinfo-icon (CQMinfo-icon-2815)

Logic

  • Replaced 'Discharge status' attribute with 'Admission Source' and 'Discharge Disposition' attributes for 'Encounter, Performed' and 'Encounter, Active' datatypes to align with QDMinfo-icon 5.3 changes.

    Measure Section: Denominator Exclusions

    Source of Change: Standards Update

  • Added supplemental timing attributes to most datatypes in QDM 5.3 to facilitate accurate retrieval of time related information within CQLinfo-icon logic. Timing attributes now include a time interval, such as prevalence period or relevant period, and/or actual time of documentation with Author Datetime. Relevant period is the general method to describe start and stop times for datatypes. Prevalence period is used for some datatypes to more accurately define onset and abatement times.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Assigned cardinality to each attribute to be more explicit in guiding specificationinfo-icon and implementation of QDM data elements. Cardinality refers to the number of instances of the attribute that can be included in the measure description. Cardinality for most attributes is 0.. 1 (i.e., can occur up to 1 time), but some attributes have a cardinality of 0.. * (i.e., can occur multiple times).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • CQL libraries contain sets of CQL definitions, or CQL expression statements. A context statement, patient or population, can now be used in a CQL library to clearly establish how the subsequent list of CQL expressions will be interpreted. A 'Population' context will interpret the CQL expression with reference to the entire population of the item being counted, patients or encounters. A 'Patient' context will interpret the CQL expression with reference to a single patient. Context statements are not required, but one or more context statements may be used within a library to help clarify how the CQL expressions will be interpreted. Patient context is the default if none is specified.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Removed the 'Face-To-Face Interaction' data element and added relevant SNOMED codes to the Encounter Grouping value setsinfo-icon to better align between the SNOMED and CPT encounter codes.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Replaced measure-defined definitions with similar definitions and functions from CQL shared libraries for consistency across measures.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated measure logic from Quality Data Model (QDM)-based logic to Clinical Quality Language (CQL)-based logic. Information on CQL can be found at the eCQI Resource centerinfo-icon (https://ecqi.healthit.gov/cql). Information about specific versions of the new standards in use for CMS reporting periods can be found at the eCQI Resource Center (https://ecqi.healthit.gov/ecqm-tools-key-resources). Switching from QDM to CQL brings with it many changes, as well as enhanced expression capability, but only those changes with significant impact will be outlined in technical release notes. For example, in the case of timing operators, changes may only be summarized if those changes impact the measure calculation.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Setinfo-icon

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

  • Value set Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001): Added SNOMEDCT extensional value set (2.16.840.1.113883.3.464.1003.101.11.1264) including 7 codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Home Healthcare Services (2.16.840.1.113883.3.464.1003.101.12.1016): Added SNOMEDCT extensional value set (2.16.840.1.113883.3.464.1003.101.11.1265) including 11 codes.

    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 2 CPT codes (90686, 90688).

    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): Added 1 CVX code (31).

    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): Added 1 ICD10CM code (Z22.51).

    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 2 SNOMEDCT codes (733834006, 733835007).

    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): Added 23 SNOMEDCT 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): Deleted 1 CPT code (90721).

    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): Deleted 2 CPT codes (90645, 90646, 90721).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Pneumococcal Conjugate Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1046): Deleted 1 CPT code (90669).

    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): Added 26 SNOMEDCT codes and deleted 1 SNOMEDCT code (72050006).

    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 5 SNOMEDCT codes (724177005, 724361001, 725135004, 725136003, 725290000).

    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 1 CVX code (150).

    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): Added 1 CVX code (152).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Rotavirus Vaccine (3 dose schedule) (2.16.840.1.113883.3.464.1003.196.12.1223): Added 1 CVX code (122).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Face-to-Face Interaction (2.16.840.1.113883.3.464.1003.101.12.1048): Removed Face-to-Face Interaction.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 11 SOP codes (299, 32127, 32128, 391, 517, 524, 614, 621, 622, 623, 629) and deleted 3 SOP codes (63, 64, 69).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Replaced SNOMEDCT single code value sets with direct referenced codes. A direct referenced code is a single concept code that is used to describe a clinical element directly within the logic. The use of direct referenced codes replaces the need for single code value sets. Measures using other code systems in single value sets may optionally transition to direct referenced codes.

    Measure Section: QDM Data Elements

    Source of Change: Standards Update

  • Replaced CPT single code value sets with direct referenced codes. A direct referenced code is a single concept code that is used to describe a clinical element directly within the logic. The use of direct referenced codes replaces the need for single code value sets. Measures using other code systems in single value sets may optionally transition to direct referenced codes.

    Measure Section: QDM Data Elements

    Source of Change: Standards Update

  • Replaced CVX single code value sets with direct referenced codes. A direct referenced code is a single concept code that is used to describe a clinical element directly within the logic. The use of direct referenced codes replaces the need for single code value sets. Measures using other code systems in single value sets may optionally transition to direct referenced codes.

    Measure Section: QDM Data Elements

    Source of Change: Standards Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Deleted 1 SOP code (24).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Rubella (2.16.840.1.113883.3.464.1003.110.12.1037): Added 3 SNOMEDCT codes (10759761000119100, 231985001, 51490003) and deleted 3 SNOMEDCT codes (1092351000119107, 111868009, 302811004).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Hepatitis A Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1041): Added 13 SNOMEDCT codes.

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Inactivated Polio Vaccine (IPV) Administered (2.16.840.1.113883.3.464.1003.110.12.1045): Added 1 SNOMEDCT code (412762002).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Measles (2.16.840.1.113883.3.464.1003.110.12.1053): Deleted 2 SNOMEDCT codes (192685000, 233625007).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Hepatitis B (2.16.840.1.113883.3.464.1003.110.12.1025): Added 1 SNOMEDCT code (153091000119109).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set DTaP Vaccine (2.16.840.1.113883.3.464.1003.196.12.1214): Added 1 CVX code (107).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Malignant Neoplasm of Lymphatic and Hematopoietic Tissue (2.16.840.1.113883.3.464.1003.108.12.1009): Added 77 SNOMEDCT codes and deleted 45 SNOMEDCT codes. Deleted 35 ICD10CM codes.

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set DTaP Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1022): Added 2 SNOMEDCT codes (312870000, 399014008).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Haemophilus Influenzae Type B (HiB) Vaccine Administered (2.16.840.1.113883.3.464.1003.110.12.1043): Added 1 SNOMEDCT code (312870000).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Disorders of the Immune System (2.16.840.1.113883.3.464.1003.120.12.1001): Added 20 SNOMEDCT codes and deleted 225 SNOMEDCT codes.

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Intussusception (2.16.840.1.113883.3.464.1003.199.12.1056): Added 3 SNOMEDCT codes (38397000, 721651002, 721676001) and deleted 1 SNOMEDCT code (91446004).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Pneumococcal Conjugate Vaccine (2.16.840.1.113883.3.464.1003.196.12.1221): Deleted 1 CVX code (100).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Varicella Zoster (2.16.840.1.113883.3.464.1003.110.12.1039): Added 3 SNOMEDCT codes (12561000132105, 331071000119101, 402899000) and deleted 1 SNOMEDCT code (10491005).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set HIV (2.16.840.1.113883.3.464.1003.120.12.1003): Added 58 SNOMEDCT codes.

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

External Resources