CMS 117v11: 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 have a visit during the measurement period
Numerator

Diphtheria, 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.
Denominator Exceptions None
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

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

  • Age = 2 years during the Measurement Period

    AND

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

CPT: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99391, 99392, 99393, 99394, 98969, 98970, 98971, 98972, 99421, 99422, 99423, 99458, 98966, 98967, 98968, 99441, 99442, 99443

HCPCS: G0071, G2010, G2012, G2061, G2062, G2063

A patient will be excluded from this measure if they meet any of the following conditions:

  • Was diagnosed with severe combined immunodeficiency, disorders of the immune system, HIV, malignant neoplasm of lymphatic and hematopoietic tissue, or intussusception on or before their 2nd birthday

  • Is in hospice care for any part of the Measurement Period

Diagnoses are documented in the Assessment tab of an encounter. A comprehensive list of eligible diagnosis codes for severe combined immunodeficiency, disorders of the immune system, HIV, malignant neoplasm of lymphatic and hematopoietic tissue, and intussusception can be located here.

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

CPT: 99377, 99378

HCPCS: G0182

Order Status must be marked as Pending or Complete.

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

HCPCS: G9996, G9473, G9474, G9475, G9476, G9477, G9478, G9479, Q5003, Q5004, Q5005, Q5006, Q5007, Q5008, Q5010, S9126, T2042, T2043, T2044, T2045, T2046

Order Status must be marked as Complete.

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)

  • DTap, Hib (3 or 4 dose), PCV, IPV, and RV ( 2 or 3 dose) vaccines must be administered from 42 days of age up to 2 years old.

  • Flu vaccines must be administered from 180 days of age up to 2 years old.

    • If administering the LAIV flu vaccine, the LAIV must be administered on the date of the patient's 2nd birthday.

  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.

Some of the eligible diagnosis codes for the following conditions 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 Encephalitis Due to Diphtheria, Tetanus or Pertussis Vaccine

Eligible MMR Conditions

  • Diagnosis of Measles

  • Diagnosis of Mumps

  • Diagnosis of Rubella

Eligible Hib Conditions

  • Diagnosis of Anaphylaxis due to Haemophilus Influenzae Type B Vaccine

Eligible Hep B Conditions

  • Diagnosis of Anaphylaxis due to Hepatitis B Vaccine
  • Diagnosis of Hepatitis B

Eligible VZV Conditions

  • Diagnosis of Varicella Zoster

Eligible Hep A Conditions

  • Diagnosis of Hepatitis A

Eligible RV Conditions

  • Diagnosis of Anaphylaxis due to Rotavirus Vaccine

https://ecqi.healthit.gov/ecqm/ec/2023/cms117v11

 

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