MIPS Performance Period 2023 and 2024 Information on Quality ID 240/CMS117: Childhood Immunization Status

The Centers for Medicare & Medicaid Services (CMS) would like to make implementers aware of a known issue for Quality ID 240/CMS117: Childhood Immunization Status for 2023 (CMS117v11) and 2024 (CMS117v12) Merit-Based Incentive Payment System (MIPS) performance periods. 

On June 22, 2023, the Advisory Committee on Immunization Practices (ACIP) convened and approved recommendations for the use of 20-valent pneumococcal conjugate vaccine (PCV20) in U.S. children. The ACIP recommendations were adopted by the Centers for Disease Control and Prevention (CDC) Director on June 27, 2023, and are official (see here). This recommendation impacts the value set for the Childhood Immunization Status electronic clinical quality measure (eCQM). CMS and the steward are working to update the value sets for the 2025 MIPS performance period. For the 2023 and 2024 MIPS performance periods, implementers may map the pneumococcal conjugate vaccine 20 valent to unspecified formulation or CVX code 109 or CVX code 152 in the 'Pneumococcal Conjugate Vaccine' (OID: 2.16.840.1.113883.3.464.1003.196.12.1221) value set. Equivalent services can be mapped to the measure's value set. If mapping is done, implementers should maintain documentation in case of a CMS audit. 

For questions about this eCQM, please submit an inquiry to The Office of the National Coordinator Project Tracking System eCQM Issue Tracker.