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
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 5.6. 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 have a visit during the measurement period | Webchart Instructions |
| Denominator | Equals Initial Population | Webchart Instructions |
| Denominator Exclusions | Exclude 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 |
| Numerator | DTaP
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.
IPV
Children with either of the following on or before the child’s second birthday meet criteria:
- At least three IPV vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth.
- Anaphylaxis due to the IPV vaccine.
MMR
Children with any of the following meet criteria:
- At least one MMR vaccination on or between the child’s first and second birthdays.
- Anaphylaxis due to the MMR vaccine on or before the child’s second birthday.
- All of the following anytime on or before the child’s second birthday (on the same or different date of service):
- History of measles.
- History of mumps.
- History of rubella.
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.
Hep 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.
- 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.
VZV
Children with any 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.
- Anaphylaxis due to the VZV vaccine on or before the child’s second birthday.
- History of varicella zoster (e.g., chicken pox) illness on or before the child’s second birthday.
PCV
Children with either of the following on or before the child’s second birthday meet criteria:
- 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.
- Anaphylaxis due to the pneumococcal vaccine.
Hep A
Children with any 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.
- Anaphylaxis due to the hepatitis A vaccine on or before the child’s second birthday.
- History of hepatitis A illness on or before the child’s second birthday.
RV
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.
Flu
Children with either of the following on or before their second birthday meet criteria:
- 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 a Live Attenuated Influenza Vaccine (LAIV) vaccination administered on the child’s second birthday. Do not count a LAIV vaccination administered before the child’s second birthday.
- Anaphylaxis due to the influenza vaccine. | Webchart Instructions |
| Numerator Exclusions | Not Applicable | Webchart Instructions |
| Denominator Exceptions | None | |
Details
| Full eMeasure Code |
eMeasure Identifier |
Measure Year |
Version |
NQF # |
GUID |
| CMS117v12 |
|
2024 |
12.0.000 |
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 indicates 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 (CDC, 2019). One study estimated that routine childhood vaccines administered in 2019 prevented 24 million diseases (Talbird et al., 2022). Another recent study estimated that routine childhood vaccinations prevented 17.8 million cases of disease and 31,000 deaths for children born in 2017, in addition to saving $13.7 billion in health care costs (Carrico et al., 2022).
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 (CDC, 2019).
Clinical Recommendation Statement
This measure looks for childhood vaccinations that should be completed by age 2, in accordance with the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (CDC ACIP) recommended child and adolescent immunization schedule (CDC ACIP, 2022).
-- For the 2022–23 season, see the 2022–23 ACIP influenza vaccine recommendations (Grohskopf, 2022).
Definition
Recommended vaccines: Vaccines and the schedule of vaccines as recommended by the 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 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 |
2.16.840.1.113883.3.67.1.101.1.269 |
| Diagnosis |
HIV |
2.16.840.1.113883.3.464.1003.120.12.1003 |
| Diagnosis |
Hospice Diagnosis |
2.16.840.1.113883.3.464.1003.1165 |
| 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
CITATIONCarrico J, La EM, Talbird SE, et al. Value of the Immunization Program for Children in the 2017 US Birth Cohort. Pediatrics. 2022;150(3):e2021056007. doi:10.1542/peds.2021-056007
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
CITATIONCenters for Disease Control and Prevention. (2022). Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger, United States. Retrieved September 2, 2022, from https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html
CITATIONGrohskopf LA, Blanton LH, Ferdinands JM, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022–23 Influenza Season. MMWR Recomm Rep 2022;71(No. RR-1):1–28. DOI: http://dx.doi.org/10.15585/mmwr.rr7101a1
CITATIONTalbird SE, Carrico J, La EM, et al. Impact of Routine Childhood Immunization in Reducing Vaccine-Preventable Diseases in the United States. Pediatrics. 2022;150(3):e2021056013. doi:10.1542/peds.2021-056013
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Source:
https://ecqi.healthit.gov/ecqm/measures/cmsv1