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
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 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 who are in hospice care for any part of 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 |
| 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
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Source:
https://ecqi.healthit.gov/ecqm/measures/cmsv1