Childhood Immunization Status

Last updated: May 17, 2016

CMS Measure ID: CMS117v4
Version: 4
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 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
National Quality Strategy Domain: Community, Population and Public Health
Next Version: Childhood Immunization Status
Previous Version: Childhood Immunization Status
Measure Score: Proportion
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

Release Notes

Header

  • Copyright updated.
  • Disclaimer updated.
  • eMeasure version number incremented.

Logic

  • Changed data type of 'result' or 'finding' to 'performed'.
  • Introduced function 'satisfies all' to specify that qualifying events must meet all conditions from a set of conditions or 'satisfies any' to specify that qualifying events must meet at least one condition from a set of conditions to streamline expression logic.
  • Introduced variables $RotavirusVaccineDose2Schedule, $RotavirusVaccineDose3Schedule, $RotavirusVaccineAdminDose2Schedule and $RotavirusVaccineAdminDose3Schedule to allow re-use of logical expressions and reduce redundancy/complexity.
  • Replaced 'Measurement Start Date' and 'Measurement End Date' with 'Measurement Period' and as necessary replaced existing timing operator (e.g., replacing 'starts before start of' with 'starts before end of').
  • Replaced 'ORs' with 'Union of' operator to provide a mechanism for specifying that qualifying event(s) must be a member of at least one of the data elements being unioned (if appropriate for measure intent).
  • Replaced 'ORs' with 'Union of' operator to provide a mechanism for specifying that qualifying event(s) must be a member of at least one of the data elements being unioned (if appropriate for measure intent).

Value Sets

  • Updated the antigen test value sets for measles, mumps, rubella, and Varicella to reflect the tests and results that are positive. The titer tests must have a titer of 1.10 or higher. The tests for the IgG antibody presence must be positive.
  • Value set Disorders of the Immune System (OID 2.16.840.1.113883.3.464.1003.120.12.1001): Added 1 ICD10CM code (D81.4) and deleted 1 ICD10CM code (M35.9).
  • Value set Encephalopathy (OID 2.16.840.1.113883.3.464.1003.114.12.1007): Deleted 2 ICD10CM codes (G04.01, G04.02).
  • Value set Hepatitis B (OID 2.16.840.1.113883.3.464.1003.110.12.1025): Added 4 ICD10CM codes (B18.0, B18.1, B19.10, B19.11).
  • Value set HIV (OID 2.16.840.1.113883.3.464.1003.120.12.1003): Added 2 SNOMED codes (405631006, 91948008).
  • Value set Influenza Vaccine (OID 2.16.840.1.113883.3.464.1003.196.12.1218): Added 4 CVX codes (135, 153, 155, 161).
  • Value set Influenza Vaccine Administered (OID 2.16.840.1.113883.3.464.1003.110.12.1044): Added 2 CPT codes (90673, 90685).
  • Value set Malignant Neoplasm of Lymphatic and Hematopietic Tissue (OID 2.16.840.1.113883.3.464.1003.108.12.1009): Added 350 ICD10CM codes and deleted 7 ICD10CM codes.
  • Value set Measles Antibody Test (IgG Antibody Titer) (OID 2.16.840.1.113883.3.464.1003.198.12.1059): Added value set to this measure.
  • Value set Measles Antibody Test (IgG presence) (OID 2.16.840.1.113883.3.464.1003.198.12.1060): Added value set to this measure.
  • Value set Measles, Mumps and Rubella (MMR) Vaccine Administered (OID 2.16.840.1.113883.3.464.1003.110.12.1031): Added 1 SNOMED code (43373003).
  • Value set Mumps Antibody Test (IgG Antibody Titer) (OID 2.16.840.1.113883.3.464.1003.198.12.1061): Added value set to this measure.
  • Value set Mumps Antibody Test (IgG presence) (OID 2.16.840.1.113883.3.464.1003.198.12.1062): Added value set to this measure.
  • Value set Rubella Antibody Test (IgG Antibody presence) (OID 2.16.840.1.113883.3.464.1003.198.12.1064): Added value set to this measure.
  • Value set Rubella Antibody Test (IgG Antibody Titer) (OID 2.16.840.1.113883.3.464.1003.198.12.1063): Added value set to this measure.
  • Value set Varicella Zoster Antibody Test (IgG Antibody Presence) (OID 2.16.840.1.113883.3.464.1003.198.12.1067): Added value set to this measure.
  • Value set Varicella Zoster Antibody Test (IgG Antibody Titer) (OID 2.16.840.1.113883.3.464.1003.198.12.1066): Added value set to this measure.

External Resources