Measure: CMS117
Childhood Immunization Status
Measure Versions
| eMeasure Code |
Measure Year |
Full Version Number |
Title |
| CMS117v12 |
2024 |
12.0.000 |
Childhood Immunization Status |
| 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
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, 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 varicella vaccines if they have cancer of lymphoreticular or histiocytic tissue, multiple myeloma, leukemia, have had an anaphylactic reaction to neomycin, have immunodeficiency, 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.
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 Population | Children who turn 2 years of age during the measurement period and who have a visit during the measurement period | Webchart Instructions |
| Denominator | Equals Initial Population | Webchart Instructions |
| Denominator Exclusions | Exclude patients whose hospice care overlaps the measurement period | Webchart Instructions |
| Numerator | 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 | Webchart Instructions |
| Numerator Exclusions | Not Applicable | Webchart Instructions |
| Denominator Exceptions | None | |
Details
| Full eMeasure Code |
eMeasure Identifier |
Measure Year |
Version |
NQF # |
GUID |
| CMS117v9 |
|
2021 |
9.2.000 |
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 2019 (Centers for Disease Control and Prevention, 2019)
Hepatitis B (HepB)
"(minimum age: birth)
Birth dose (monovalent HepB vaccine only)
-- Mother is HBsAg-negative: 1 dose within 24 hours of birth for all medically stable infants ?2,000 grams. Infants <2,000 grams: administer 1 dose at chronological age 1 month or hospital discharge.
-- Mother is HBsAg-positive:
- Administer HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) (at separate anatomic sites) within 12 hours of birth, regardless of birth weight. For infants <2,000 grams, administer 3 additional doses of vaccine (total of 4 doses) beginning at age 1 month.
- Test for HBsAg and anti-HBs at age 9–12 months. If HepB series is delayed, test 1–2 months after final dose.
-- Mother’s HBsAg status is unknown:
- Administer HepB vaccine within 12 hours of birth, regardless of birth weight.
- For infants <2,000 grams, administer 0.5 mL of HBIG in addition to HepB vaccine within 12 hours of birth. Administer 3 additional doses of vaccine (total of 4 doses) beginning at age 1 month.
- Determine mother’s HBsAg status as soon as possible. If mother is HBsAg-positive, administer 0.5 mL of HBIG to infants ?2,000 grams as soon as possible, but no later than 7 days of age.
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, acellular pertussis vaccinations (DTap)
"(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 given as early as age 12 months if at least 6 months have elapsed since dose 3.
- Retrospectively: A 4th dose that was inadvertently given as early as 12 months may be counted if at least 4 months have elapsed since dose 3."
Haemophilus influenzae type b (Hib)
"(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"
Poliovirus (inactivated) (IPV)
" (minimum age: 6 weeks)
Routine vaccination
-- 4-dose series at ages 2, 4, 6–18 months, 4–6 years; administer the final dose on or after the 4th birthday and at least 6 months after the previous dose.
-- 4 or more doses of IPV can be administered before the 4th birthday when a combination vaccine containing IPV is used. However, a dose is still recommended after the 4th birthday and at least 6 months after the previous dose."
Measles, mumps, and rubella (MMR)
"(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"
Pneumococcal
"(minimum age: 6 weeks [PCV13], 2 years [PPSV23])
Routine vaccination with PCV13
-- 4-dose series at 2, 4, 6, 12–15 months"
Varicella (VAR)
"(minimum age: 12 months)
Routine vaccination
-- 2-dose series: 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 (HepA)
"(minimum age: 12 months for routine vaccination)
Routine vaccination
-- 2-dose series (Havrix 6–12 months apart or Vaqta 6–18 months apart, minimum interval 6 months); a series begun before the 2nd birthday should be completed even if the child turns 2 before the second dose is administered."
Rotavirus (RV)
"(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 (inactivated) influenza vaccine (IIV)
"(minimum age: 6 months [IIV], 2 years [LAIV ], 18 years [RIV])
Routine vaccination
-- 1 dose any influenza vaccine appropriate for age and health status annually (2 doses separated by at least 4 weeks for children 6 months–8 years who did not receive at least 2 doses of influenza vaccine before July 1, 2018)"
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 |
Anaphylactic Reaction to Hepatitis A Vaccine |
2.16.840.1.113883.3.464.1003.199.12.1026 |
| 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 |
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 |
| 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 |
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
Centers for Disease Control and Prevention (CDC). (2019). Common Questions About Vaccines. Retrieved October 17, 2019, from https://www.cdc.gov/vaccines/parents/FAQs.html
American Academy of Pediatrics. (2013). Why Immunize Your Child. Retrieved October 17, 2019, from HealthyChildren.org website: http://www.healthychildren.org/english/safety-prevention/immunizations/Pages/Why-Immunize-Your-Child.aspx
Zhou, 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
Centers for Disease Control and Prevention. (2019). Recommended Child and Adolescent Immunization Schedule for ages 18 years or younger. Retrieved October 22, 2019, from https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf
Centers for Disease Control and Prevention. (2018). Why Are Childhood Vaccines So Important? Retrieved October 23, 2019, from https://www.cdc.gov/vaccines/vac-gen/howvpd.htm
Disclaimer
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Source:
https://ecqi.healthit.gov/ecqm/measures/cmsv9