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Measure: CMS117

Childhood Immunization Status

Measure Versions

eMeasure Code Measure Year Full Version Number Title
CMS117v11 2023 11 Childhood Immunization Status
CMS117v10 2022 10.0.000 Childhood Immunization Status
CMS117v9 2021 9.2.000 Childhood Immunization Status
CMS117v8 2020 8.3.000 Childhood Immunization Status
CMS117v7 2019 7.2.000 Childhood Immunization Status
CMS117v6 2018 6.2.000 Childhood Immunization Status
CMS117v5 2017 5.1.000 Childhood Immunization Status

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 or four 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

Guidance

Numerator criteria includes evidence of receipt of the recommended vaccine or the following: -- DTaP: Adverse reaction to the DTaP or Td vaccine; or encephalopathy due to DTaP or Td vaccination -- Polio (IPV) vaccine: Adverse reaction to the IPV vaccine, streptomycin, polymyxin B, or neomycin -- MMR Vaccination: Immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma, or leukemia; adverse reaction to neomycin; history of measles, mumps, or rubella; or a seropositive result for the antigens -- Hib: Adverse reaction to the Hib vaccine -- Hepatitis B: Seropositive result for the antigen, adverse reaction to the hepatitis B vaccine, adverse reaction to common baker’s yeast, or a history of hepatitis B illness -- Chicken pox (varicella zoster): Seropositive result for the antigen; immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma, or leukemia; adverse reaction to neomycin; or a history of varicella zoster -- Pneumococcal: Adverse reaction to the pneumococcal vaccine -- Hepatitis A: Seropositive result for the antigen, adverse reaction to the hepatitis A vaccine, or a history of hepatitis A illness -- Rotavirus: Adverse reaction to the rotavirus vaccine, severe combined immunodeficiency, or a history of intussusception -- Influenza: Adverse reaction to the influenza vaccine; immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma, or leukemia; or adverse reaction to neomycin The measure allows a grace period by measuring compliance with these recommendations between birth and age two. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Patient Group Definitions

Group Description Instructions Links
Initial PopulationChildren who turn 2 years of age during the measurement period and who have a visit during the measurement periodWebchart Instructions
DenominatorEquals Initial PopulationWebchart Instructions
Denominator ExclusionsExclude patients who are in hospice care for any part of the measurement period.Webchart Instructions
NumeratorChildren 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 birthdayWebchart Instructions
Numerator ExclusionsNot ApplicableWebchart Instructions
Denominator ExceptionsNone

Details

Full eMeasure Code eMeasure Identifier Measure Year Version NQF # GUID
CMS117v10 2022 10.0.000 Not Applicable b2802b7a-3580-4be8-9458-921aea62b78c
Steward Developer Endorsed By
National Committee for Quality Assurance National Committee for Quality Assurance
Scoring Method Measure Type Stratification Risk Adjustment
Proportion PROCESS None None

Rate Aggregation

None

Improvement Notation

Higher score equals better quality

Rationale

Infants and toddlers are particularly vulnerable to infectious diseases because their immune systems have not built up the necessary defenses to fight infection (Centers for Disease Control and Prevention (CDC, 2019). Most childhood vaccines are between 90 and 99 percent effective in preventing diseases (American Academy of Pediatrics, 2013). Vaccination of each U.S. birth cohort with the current childhood immunization schedule prevents approximately 42,000 deaths and 20 million cases of disease and saves nearly $14 billion in direct costs and $69 billion in societal costs each year (Zhou et al., 2014). Immunizing a child not only protects that child's health but also the health of the community, especially for those who are not immunized or are unable to be immunized due to other health complications (Centers for Disease Control and Prevention, 2018).

Clinical Recommendation Statement

Recommended Child and Adolescent Immunization Schedule
for ages 18 years or younger, United States 2020 (Centers for Disease Control and Prevention, 2020)

Hepatitis B vaccination
(minimum age: birth)
"Routine series
-- 3-dose series at 0, 1–2, 6–18 months (use monovalent HepB vaccine for doses administered before age 6 weeks)
-- Infants who did not receive a birth dose should begin the series as soon as feasible (see Table 2).
-- Administration of 4 doses is permitted when a combination vaccine containing HepB is used after the birth dose.
-- Minimum age for the final (3rd or 4th ) dose: 24 weeks
-- Minimum intervals: dose 1 to dose 2: 4 weeks / dose 2 to
dose 3: 8 weeks / dose 1 to dose 3: 16 weeks (when 4 doses are administered, substitute "dose 4" for "dose 3" in these calculations) "

Diphtheria, tetanus, and pertussis (DTaP) vaccination (minimum age: 6 weeks [4 years for Kinrix or Quadracel])
"Routine vaccination
-- 5-dose series at 2, 4, 6, 15–18 months, 4–6 years
- Prospectively: Dose 4 may be administered as early as age 12 months if at least 6 months have elapsed since dose 3.
- Retrospectively: A 4th dose that was inadvertently administered as early as 12 months may be counted if at least 4 months have elapsed since dose 3. "

Haemophilus influenzae type b vaccination
(minimum age: 6 weeks)
"Routine vaccination
-- ActHIB, Hiberix, or Pentacel: 4-dose series at 2, 4, 6, 12–
15 months
-- PedvaxHIB: 3-dose series at 2, 4, 12–15 months" 

Pneumococcal vaccination
(minimum age: 6 weeks [PCV13], 2 years [PPSV23])
"Routine vaccination with PCV13
-- 4-dose series at 2, 4, 6, 12–15 months"

Poliovirus vaccination
(minimum age: 6 weeks)
"Routine vaccination
-- 4-dose series at ages 2, 4, 6–18 months, 4–6 years; administer the final dose at or after age 4 years and at least 6 months after the previous dose.
-- 4 or more doses of IPV can be administered before age 4 years when a combination vaccine containing IPV is used. However, a dose is still recommended at or after age 4 years and at least 6 months after the previous dose"

Measles, mumps, and rubella vaccination
(minimum age: 12 months for routine vaccination)
"Routine vaccination
-- 2-dose series at 12–15 months, 4–6 years
-- Dose 2 may be administered as early as 4 weeks after dose 1."

Varicella vaccination
(minimum age: 12 months)
"Routine vaccination
-- 2-dose series at 12–15 months, 4–6 years
-- Dose 2 may be administered as early as 3 months after dose 1 (a dose administered after a 4-week interval may be counted)."

Hepatitis A vaccination
(minimum age: 12 months for routine vaccination)
"Routine vaccination
-- 2-dose series (minimum interval: 6 months) beginning at age 12 months"

Rotavirus vaccination
(minimum age: 6 weeks)
"Routine vaccination
-- Rotarix: 2-dose series at 2 and 4 months
-- RotaTeq: 3-dose series at 2, 4, and 6 months
-- If any dose in the series is either RotaTeq or unknown, default to 3-dose series"

Influenza vaccination
(minimum age: 6 months [IIV], 2 years [LAIV],
18 years [recombinant influenza vaccine, RIV])
"Routine vaccination
-- Use any influenza vaccine appropriate for age and health status annually:
- 2 doses, separated by at least 4 weeks, for children age 6
months–8 years who have received fewer than 2 influenza
vaccine doses before July 1, 2019, or whose influenza vaccination history is unknown (administer dose 2 even if the child turns 9 between receipt of dose 1 and dose 2)
- 1 dose for children age 6 months–8 years who have received at least 2 influenza vaccine doses before July 1, 2019
- 1 dose for all persons age 9 years and older
-- For the 2020–21 season, see the 2020–21 ACIP influenza vaccine recommendations."

Definition

Recommended vaccines: Vaccines and the schedule of vaccines as recommended by the Advisory Committee on Immunization Practices (ACIP) for children two years of age. The measure may differ slightly from the ACIP recommendations because the measure focuses on immunizations that are appropriate by age 2. Also, there may be small differences when there are shortages for a particular vaccine.

Transmission Format

TBD

Applicable Value Sets

Category Value Set OID
Diagnosis Anaphylactic Reaction to Common Baker's Yeast 2.16.840.1.113883.3.464.1003.199.12.1032
Diagnosis Anaphylactic Reaction to DTaP Vaccine 2.16.840.1.113883.3.464.1003.199.12.1031
Diagnosis Disorders of the Immune System 2.16.840.1.113883.3.464.1003.120.12.1001
Diagnosis Encephalopathy due to Childhood Vaccination 2.16.840.1.113883.3.464.1003.114.12.1007
Diagnosis Hepatitis A 2.16.840.1.113883.3.464.1003.110.12.1024
Diagnosis Hepatitis B 2.16.840.1.113883.3.464.1003.110.12.1025
Diagnosis HIV 2.16.840.1.113883.3.464.1003.120.12.1003
Diagnosis Intussusception 2.16.840.1.113883.3.464.1003.199.12.1056
Diagnosis Malignant Neoplasm of Lymphatic and Hematopoietic Tissue 2.16.840.1.113883.3.464.1003.108.12.1009
Diagnosis Measles 2.16.840.1.113883.3.464.1003.110.12.1053
Diagnosis Mumps 2.16.840.1.113883.3.464.1003.110.12.1032
Diagnosis Rubella 2.16.840.1.113883.3.464.1003.110.12.1037
Diagnosis Severe Combined Immunodeficiency 2.16.840.1.113883.3.464.1003.120.12.1007
Diagnosis Varicella Zoster 2.16.840.1.113883.3.464.1003.110.12.1039
Encounter, Performed Encounter Inpatient 2.16.840.1.113883.3.666.5.307
Encounter, Performed Home Healthcare Services 2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed Office Visit 2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed Online Assessments 2.16.840.1.113883.3.464.1003.101.12.1089
Encounter, Performed Preventive Care - Established Office Visit, 0 to 17 2.16.840.1.113883.3.464.1003.101.12.1024
Encounter, Performed Preventive Care- Initial Office Visit, 0 to 17 2.16.840.1.113883.3.464.1003.101.12.1022
Encounter, Performed Telephone Visits 2.16.840.1.113883.3.464.1003.101.12.1080
Intervention, Order Hospice care ambulatory 2.16.840.1.113762.1.4.1108.15
Intervention, Performed Hospice care ambulatory 2.16.840.1.113762.1.4.1108.15
Laboratory Test, Performed Anti Hepatitis B Virus Surface Ab 2.16.840.1.113883.3.464.1003.198.12.1073
Laboratory Test, Performed Hepatitis A Antigen Test 2.16.840.1.113883.3.464.1003.198.12.1033
Laboratory Test, Performed Measles Antibody Test (IgG Antibody presence) 2.16.840.1.113883.3.464.1003.198.12.1060
Laboratory Test, Performed Measles Antibody Test (IgG Antibody Titer) 2.16.840.1.113883.3.464.1003.198.12.1059
Laboratory Test, Performed Mumps Antibody Test (IgG Antibody presence) 2.16.840.1.113883.3.464.1003.198.12.1062
Laboratory Test, Performed Mumps Antibody Test (IgG Antibody Titer) 2.16.840.1.113883.3.464.1003.198.12.1061
Laboratory Test, Performed Rubella Antibody Test (IgG Antibody presence) 2.16.840.1.113883.3.464.1003.198.12.1064
Laboratory Test, Performed Rubella Antibody Test (IgG Antibody Titer) 2.16.840.1.113883.3.464.1003.198.12.1063
Laboratory Test, Performed Varicella Zoster Antibody Test (IgG Antibody Presence) 2.16.840.1.113883.3.464.1003.198.12.1067
Laboratory Test, Performed Varicella Zoster Antibody Test (IgG Antibody Titer) 2.16.840.1.113883.3.464.1003.198.12.1066
Patient Characteristic Ethnicity Ethnicity 2.16.840.1.114222.4.11.837
Patient Characteristic Payer Payer 2.16.840.1.114222.4.11.3591
Patient Characteristic Race Race 2.16.840.1.114222.4.11.836
Patient Characteristic Sex ONC Administrative Sex 2.16.840.1.113762.1.4.1
Procedure, Performed DTaP Vaccine Administered 2.16.840.1.113883.3.464.1003.110.12.1022
Procedure, Performed Hepatitis A Vaccine Administered 2.16.840.1.113883.3.464.1003.110.12.1041
Procedure, Performed Hepatitis B Vaccine Administered 2.16.840.1.113883.3.464.1003.110.12.1042
Procedure, Performed HiB Vaccine (3 dose schedule) Administered 2.16.840.1.113883.3.464.1003.110.12.1084
Procedure, Performed HiB Vaccine (4 dose schedule) Administered 2.16.840.1.113883.3.464.1003.110.12.1086
Procedure, Performed Inactivated Polio Vaccine (IPV) Administered 2.16.840.1.113883.3.464.1003.110.12.1045
Procedure, Performed Influenza Vaccine Administered 2.16.840.1.113883.3.464.1003.110.12.1044
Procedure, Performed Influenza Virus LAIV Procedure 2.16.840.1.113883.3.464.1003.110.12.1088
Procedure, Performed Measles, Mumps and Rubella (MMR) Vaccine Administered 2.16.840.1.113883.3.464.1003.110.12.1031
Procedure, Performed Pneumococcal Conjugate Vaccine Administered 2.16.840.1.113883.3.464.1003.110.12.1046
Procedure, Performed Rotavirus Vaccine (2 dose schedule) Administered 2.16.840.1.113883.3.464.1003.110.12.1048
Procedure, Performed Rotavirus Vaccine (3 dose schedule) Administered 2.16.840.1.113883.3.464.1003.110.12.1047
Procedure, Performed Varicella Zoster Vaccine (VZV) Administered 2.16.840.1.113883.3.464.1003.110.12.1040

References

CITATIONCenters for Disease Control and Prevention (CDC). (2019). Common Questions About Vaccines. Retrieved September 10, 2020, from https://www.cdc.gov/vaccines/parents/FAQs.html
CITATIONAmerican Academy of Pediatrics. (2013). Why Immunize Your Child. Retrieved September 10, 2020, from: http://www.healthychildren.org/english/safety-prevention/immunizations/Pages/Why-Immunize-Your-Child.aspx
CITATIONZhou, F., Shefer, A., Wenger, J., Messonnier, M., Wang, L. Y., Lopez, A., … Rodewald, L. (2014). Economic evaluation of the routine childhood immunization program in the United States, 2009. Pediatrics, 133(4), 577–585. https://doi.org/10.1542/peds.2013-0698
CITATIONCenters for Disease Control and Prevention. (2020). Recommended Child and Adolescent Immunization Schedule for ages 18 years or younger. Retrieved September 10, 2020, from https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf

Disclaimer

The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

Copyright

This Physician Performance Measure (Measure) and related data specifications are owned and were developed by the National Committee for Quality Assurance (NCQA). NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in the Measure. The Measure can be reproduced and distributed, without modification, for noncommercial purposes (e.g., use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. (C) 2012-2020 National Committee for Quality Assurance. All Rights Reserved.

Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third party codes contained in the specifications.

CPT(R) contained in the Measure specifications is copyright 2004-2020 American Medical Association. LOINC(R) copyright 2004-2020 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2020 International Health Terminology Standards Development Organisation. ICD-10 copyright 2020 World Health Organization. All Rights Reserved.

Source: https://ecqi.healthit.gov/ecqm/measures/cmsv1