CMS 117 - Childhood Immunization Status
Covered by this topic
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
- Option 1: Record the Receipt of Immunizations (Historical)
- Within Encounter
- Open the Immunizations/Injections section of the encounter
- Using the Description autocomplete, begin typing the name of the immunizations
- Add the Date and any Reactions/Comments
- Click the Add button
- Click the Next button, or close the section
- Continue documenting the encounter as needed
- When completed, Close and Archive the encounter.
- Outside Encounter
- While in the chart, navigate to MAR/Injections from the Medical Record chart tab
- Click the Quick Add link in the upper-right of the page
- Record any historical injections
- Click the Submit button
- Within Encounter
- Option 2: Document the Administration of the Vaccines
- Within Encounter
- Open the Tests and Procedures section of the encounter
- Using the autocomplete, begin typing the name of the vaccination being administered
- Click the Add to Exam button
- After adding the new section, open the section and fill in all required fields
- Click the Next button, or close the section
- Continue documenting the encounter as needed
- When completed, Close and Archive the encounter
- Outside Encounter
- While in the chart, navigate to MAR/Injections from the Medical Record chart tab
- Click the Add Imm/Inj link in the upper-right of the page
- Fill in all required fields
- Click the Submit button
- Within Encounter
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)
Enterprise Health Documentation
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