CMS 117v9: Childhood Immunization Status

Measure: 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
Measure Type High Priority Measure Scoring
Process No A higher percentage indicates better quality
Denominator Children who turn 2 years of age during the measurement period and who have a visit during the measurement period
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
Denominator Exceptions None
Denominator Exclusions Exclude patients whose hospice care overlaps the measurement period

Patients who meet the following criteria will be included in the denominator:

  • Age is ≥ 1 year before the start of the Measurement Period

    AND

  • Age is = 2 years before the end of the Measurement Period

    AND

  • Have at least one eligible encounter during the Measurement Period finalized by the EC/EP

CPT: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99391, 99392, 99393, 99394

Patients who were in hospice care during the measurement year will be excluded from the measure.

To document hospice care services as a procedure, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

SNOMED CT: 385763009, 385765002

Order Status must be marked as Pending or Complete.

SNOMED CT codes must be added as a Favorite in Preferences > Form Data > Orders to be accessible from the Orders/Referrals tab.

A patient will be counted in the numerator if they receive the following recommended vaccines OR have documented evidence of previously having the disease OR have documented evidence of having an allergic reaction to the vaccine by their 2nd birthday:

  • 4 diphtheria, tetanus, acellular pertussis (DTap)
  • 3 polio (IPV)
  • 1 measles, mumps, rubella (MMR)
  • 3 or 4 H influenza type B (Hib)
  • 3 Hepatitis B (Hep B)
  • 1 chicken pox (VZV)
  • 4 pneumococcal conjugate (PCV)
  • 1 hepatitis A (Hep A)
  • 2 or 3 rotavirus (RV)
  • 2 influenza (flu)
  1. Go to Encounters > Immunizations > 0 to 2 tab
  2. Click the immunization name/dose button

    1. For Influenza, click the Add button

  3. Complete the fields in the Serum section

  4. Complete the applicable fields of the Administration section

  5. Click Save
  1. Go to Encounters > Immunizations > 0 to 2 tab
  2. Click the immunization name/dose button
    1. For Influenza, click the Add button
  3. Select the Historic checkbox
  4. Document the date the immunization was given in the Date field of the Administration section
  5. Click Save

If documenting H influenza type B (Hib) as a historical immunization, four entries must be documented unless a Tradename for a three-dose vaccine is selected. If documenting rotavirus (RV) as a historical immunization, three entries must be documented unless a Tradename for a two-dose vaccine is selected.

A patient’s history of the disease or allergic reaction to a vaccine can be documented in the Assessment tab of an encounter. A comprehensive list of eligible diagnosis codes for these conditions can be located here.

The eligible diagnosis codes for conditions of Diagnosis of Anaphylactic Reaction to [vaccine or ingredient] are only available as SNOMED CT codes. SNOMED codes can be added in the Assessment tab by mapping the codes to an active ICD-10 using the Map SNO button.

Eligible DTap Conditions

  • Diagnosis of Anaphylactic Reaction to DTaP Vaccine
  • Diagnosis of Encephalopathy due to Childhood Vaccination

Eligible IPV Conditions

  • Diagnosis of Anaphylactic Reaction to Inactivated Polio Vaccine (IPV)
  • Diagnosis of Anaphylactic Reaction to Streptomycin
  • Diagnosis of Anaphylactic Reaction to Polymyxin
  • Diagnosis of Anaphylactic Reaction to Neomycin

Eligible MMR Conditions

  • Diagnosis of Disorders of the Immune System
  • Diagnosis of HIV
  • Diagnosis of Malignant Neoplasm of Lymphatic and Hematopoietic Tissue
  • Diagnosis of Anaphylactic Reaction to Neomycin
  • Diagnosis of Measles
  • Diagnosis of Mumps
  • Diagnosis of Rubella

Eligible Hib Conditions

  • Diagnosis of Anaphylactic Reaction to Hemophilus Influenza B (Hib) Vaccine

Eligible Hep B Conditions

  • Diagnosis of Anaphylactic Reaction to Hepatitis B Vaccine
  • Diagnosis of Anaphylactic Reaction to Common Baker's Yeast
  • Diagnosis of Hepatitis B

Eligible VZV Conditions

  • Diagnosis of Disorders of the Immune System
  • Diagnosis of HIV
  • Diagnosis of Malignant Neoplasm of Lymphatic and Hematopoietic Tissue
  • Diagnosis of Anaphylactic Reaction to Neomycin
  • Diagnosis of Varicella Zoster

Eligible PCV Conditions

  • Diagnosis of Anaphylactic Reaction to Pneumococcal Conjugate Vaccine

Eligible Hep A Conditions

  • Diagnosis of Anaphylactic Reaction to Hepatitis A Vaccine
  • Diagnosis of Hepatitis A

Eligible RV Conditions

  • Diagnosis of Anaphylactic Reaction to Rotavirus Vaccine
  • Diagnosis of Severe Combined Immunodeficiency
  • Diagnosis of Intussusception

Eligible Flu Conditions

  • Diagnosis of Anaphylactic Reaction to Influenza Vaccine
  • Diagnosis of Malignant Neoplasm of Lymphatic and Hematopoietic Tissue
  • Diagnosis of Anaphylactic Reaction to Neomycin
  • Diagnosis of HIV
  • Diagnosis of Disorders of the Immune System

https://ecqi.healthit.gov/ecqm/ep/2021/cms117v9

 

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