CMS 117 - Childhood Immunization Status

Overview

CMS117v8 (2020)
CMS117v9 (2021)
CMS117v10 (2022)

Identifiers

CMS eCQM ID	NQF eCQM ID	NQF	MIPS Quality ID
CMS117v10	–	–	240

*MIE only supports data collection and reporting using eCQM specifications

Definitions

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
Initial Patient Population	Children who turn 2 years of age during the measurement period and who have a visit during the measurement period
Denominator	Equals Initial Population
Denominator Exclusions	Exclude patients who are in hospice care for any part of 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
Numerator Exclusions	–
Denominator Exceptions	–

Additional Information

Measure Type	Process measure
Measure Scoring	Proportion measure
Granularity	Patient
Improvement Notation	Higher score indicates better quality
Domain	Community/Population Health

Clinical Instructions

Ensure all children turning 2 years of age during the measurement period have had a visit and received all of the necessary immunizations. Recording the receipt of the immunizations or the administration of the vaccines can be done within or outside of an encounter.

Workflow

1. Option 1: Record the Receipt of Immunizations (Historical)
   1. Within Encounter
      1. Open the Immunizations/Injections section of the encounter
      2. Using the Description autocomplete, begin typing the name of the immunizations
      3. Add the Date and any Reactions/Comments
      4. Click the Add button
      5. Click the Next button, or close the section
      6. Continue documenting the encounter as needed
      7. When completed, Close and Archive the encounter.
   2. Outside Encounter
      1. While in the chart, navigate to MAR/Injections from the Medical Record chart tab
      2. Click the Quick Add link in the upper-right of the page
      3. Record any historical injections
      4. Click the Submit button
2. Option 2: Document the Administration of the Vaccines
   1. Within Encounter
      1. Open the Tests and Procedures section of the encounter
      2. Using the autocomplete, begin typing the name of the vaccination being administered
      3. Click the Add to Exam button
      4. After adding the new section, open the section and fill in all required fields
      5. Click the Next button, or close the section
      6. Continue documenting the encounter as needed
      7. When completed, Close and Archive the encounter
   2. Outside Encounter
      1. While in the chart, navigate to MAR/Injections from the Medical Record chart tab
      2. Click the Add Imm/Inj link in the upper-right of the page
      3. Fill in all required fields
      4. Click the Submit button

Evidence

Initial Patient Population

Name	Value Set
Encounter, Performed: Home Healthcare Services	2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed: Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.	CPT Code 99211
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 Services, Initial Office Visit, 0 to 17	2.16.840.1.113883.3.464.1003.101.12.1022
Encounter, Performed: Preventive Care, Established Office Visit, 0 to 17	2.16.840.1.113883.3.464.1003.101.12.1024
Encounter, Performed: Telephone Visits	2.16.840.1.113883.3.464.1003.101.12.1080

Denominator Exclusions

Name	Value Set
Encounter, Performed: Encounter Inpatient	2.16.840.1.113883.3.666.5.307
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

Numerator

Name	Value Set
Diagnosis: Adverse reaction to vaccine product containing Hepatitis A virus antigen (disorder)	SNOMEDCT Code 293126009
Diagnosis: Adverse reaction to vaccine product containing Human poliovirus antigen (disorder)	SNOMEDCT Code 293117006
Diagnosis: Adverse reaction to vaccine product containing Influenza virus antigen (disorder)	SNOMEDCT Code 420113004
Diagnosis: Adverse reaction to vaccine product containing Streptococcus pneumoniae antigen (disorder)	SNOMEDCT Code 293116002
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: Anaphylaxis due to Haemophilus influenzae type b vaccine (disorder)	SNOMEDCT Code 433621000124101
Diagnosis: Anaphylaxis due to Hepatitis B vaccine (disorder)	SNOMEDCT Code 428321000124101
Diagnosis: Anaphylaxis due to rotavirus vaccine (disorder)	SNOMEDCT Code 428331000124103
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: Neomycin adverse reaction (disorder)	SNOMEDCT Code 292927007
Diagnosis: Polymyxin B adverse reaction (disorder)	SNOMEDCT Code 292992006
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: Streptomycin adverse reaction (disorder)	SNOMEDCT Code 292925004
Diagnosis: Varicella Zoster	2.16.840.1.113883.3.464.1003.110.12.1039
Immunization, Administered: DTaP Vaccine	2.16.840.1.113883.3.464.1003.196.12.1214
Immunization, Administered: Hepatitis A Vaccine	2.16.840.1.113883.3.464.1003.196.12.1215
Immunization, Administered: Hepatitis B Vaccine	2.16.840.1.113883.3.464.1003.196.12.1216
Immunization, Administered: Hib Vaccine (3 dose schedule)	2.16.840.1.113883.3.464.1003.110.12.1083
Immunization, Administered: Hib Vaccine (4 dose schedule)	2.16.840.1.113883.3.464.1003.110.12.1085
Immunization, Administered: Inactivated Polio Vaccine (IPV)	2.16.840.1.113883.3.464.1003.196.12.1219
Immunization, Administered: Influenza Vaccine	2.16.840.1.113883.3.464.1003.196.12.1218
Immunization, Administered: Influenza Virus LAIV Immunization	2.16.840.1.113883.3.464.1003.110.12.1087
Immunization, Administered: Measles, Mumps and Rubella (MMR) Vaccine	2.16.840.1.113883.3.464.1003.196.12.1224
Immunization, Administered: Pneumococcal Conjugate Vaccine	2.16.840.1.113883.3.464.1003.196.12.1221
Immunization, Administered: Rotavirus Vaccine (3 dose schedule)	2.16.840.1.113883.3.464.1003.196.12.1223
Immunization, Administered: rotavirus, live, monovalent vaccine	CVX Code 119
Immunization, Administered: Varicella Zoster Vaccine (VZV)	2.16.840.1.113883.3.464.1003.196.12.1170
Laboratory Test, Performed: Anti Hepatitis A IgG Antigen Test	2.16.840.1.113883.3.464.1003.198.12.1033
Laboratory Test, Performed: Anti Hepatitis B Virus Surface Ab	2.16.840.1.113883.3.464.1003.198.12.1073
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
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

Source(s)

eCQI CMS117