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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

Patient Group Definitions

Group Description Instructions Links
Initial PopulationChildren who turn 2 years of age during the measurement period and have a visit during the measurement periodWebchart Instructions
DenominatorEquals Initial PopulationWebchart Instructions
Denominator ExclusionsExclude children with any of the following on or before the child’s second birthday: • Severe combined immunodeficiency • Immunodeficiency • HIV • Lymphoreticular cancer, multiple myeloma or leukemia • Intussusception Exclude children who are in hospice care for any part of the measurement period.Webchart Instructions
NumeratorDiphtheria, tetanus, and pertussis (DTaP) vaccination Children with any of the following on or before the child’s second birthday meet criteria: • At least four DTaP vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth. • Anaphylaxis due to the diphtheria, tetanus or pertussis vaccine. • Encephalitis due to the diphtheria, tetanus or pertussis vaccine. Poliovirus vaccination (IPV) At least three IPV vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth. Measles, mumps, and rubella vaccination (MMR) Children with either of the following meet criteria: • At least one MMR vaccination on or between the child’s first and second birthdays. • All of the following anytime on or before the child’s second birthday (on the same or different date of service): o History of measles o History of mumps o History of rubella Haemophilus influenzae type b vaccination (HiB) Children with either of the following meet criteria on or before the child’s second birthday: • At least three HiB vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth. • Anaphylaxis due to the HiB vaccine. Hepatitis B Children with any of the following on or before the child’s second birthday meet criteria: • At least three hepatitis B vaccinations, with different dates of service. o One of the three vaccinations can be a newborn hepatitis B vaccination during the eight-day period that begins on the date of birth and ends seven days after the date of birth. For example, if the member’s date of birth is December 1, the newborn hepatitis B vaccination must be on or between December 1 and December 8. • Anaphylaxis due to the hepatitis B vaccine. • History of hepatitis B illness. Varicella vaccination (VZV) Children with either of the following meet criteria: • At least one VZV vaccination, with a date of service on or between the child’s first and second birthdays. • History of varicella zoster (e.g., chicken pox) illness on or before the child’s second birthday. Pneumococcal Conjugate At least four pneumococcal conjugate vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth. Hepatitis A Children with either of the following meet criteria: • At least one hepatitis A vaccination, with a date of service on or between the child’s first and second birthdays. • History of hepatitis A illness on or before the child’s second birthday. Rotavirus Children with any of the following meet criteria: • At least two doses of the two-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth. • At least three doses of the three-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth. • At least one dose of the two-dose rotavirus vaccine and at least two doses of the three-dose rotavirus vaccine, all on different dates of service, on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth. • Anaphylaxis due to the rotavirus vaccine on or before the child’s second birthday. Influenza At least two influenza vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 6 months (180 days) after birth. • One of the two vaccinations can be an LAIV vaccination administered on the child’s second birthday. Do not count an LAIV vaccination administered before the child’s second birthday.Webchart Instructions
Numerator ExclusionsNot ApplicableWebchart Instructions
Denominator ExceptionsNone

Details

Full eMeasure Code eMeasure Identifier Measure Year Version NQF # GUID
CMS117v11 117 2023 11 N/A b2802b7a-3580-4be8-9458-921aea62b78c
Steward Developer Endorsed By
National Committee for Quality Assurance National Committee for Quality Assurance None
Scoring Method Measure Type Stratification Risk Adjustment
Proportion Process None None

Rate Aggregation

None

Improvement Notation

Higher score indicates better quality

Rationale

Clinical Recommendation Statement


Definition

Transmission Format

Applicable Value Sets

Category Value Set OID
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 Encephalitis Due to Diphtheria, Tetanus or Pertussis Vaccine 2.16.840.1.113883.3.464.1003.1164
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 Hospice Encounter 2.16.840.1.113883.3.464.1003.1003
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 2.16.840.1.113883.3.526.3.1584
Intervention, Performed Hospice Care Ambulatory 2.16.840.1.113883.3.526.3.1584
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


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Source: https://ecqi.healthit.gov/ecqm/measures/cms117v1