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CMS 117 - Childhood Immunization Status

Updated: 06/13/2023|Views: 958

CMS 117 / Quality ID #240

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.

Denominator: Children who turn 2 years of age during the measurement period and who have a visit during the measurement period.
  • Patient’s age is calculated based on the patient’s Date of Birth, which was entered when you created the patient’s account.
  • Create a note detailing the patient’s office visit.
Denominator Exclusions:  Exclude children with any of the following on or before the child’s second birthday:
  1. Severe combined immunodeficiency
  2. Immunodeficiency
  3. HIV
  4. Lymphoreticular cancer, multiple myeloma or leukemia
  5. Intussusception
  • These conditions are documented under Problems with a Start Date.

Exclude children who are in hospice care for any part of the measurement period.

  • Hospice is documented under Hospice in History. These patients will be excluded from the denominator.
Numerator: Diphtheria, tetanus, and pertussis (DTaP) vaccination

Children with any of the following on or before the child’s second birthday meet criteria:
  1. At least four DTaP vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth.
  2. Anaphylaxis due to the diphtheria, tetanus or pertussis vaccine.
  3. Encephalitis due to the diphtheria, tetanus or pertussis vaccine.
  • Vaccines are documented in Immunizations. Vaccine may be entered as Administer New or Add Historical. Enter an Order or Recorded Date for each immunization.
  • Allergic reactions to vaccines are documented under Allergies with a Start Date.
  • Illness, conditions, or history os illness is documented under Problems with a Start Date.

Poliovirus vaccination (IPV)

  1. 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:

  1. At least one MMR vaccination on or between the child’s first and second birthdays.
  2. 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

Haemophilus influenzae type b vaccination (HiB)

Children with either of the following meet criteria on or before the child’s second birthday:

  1. At least three HiB vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth.
  2. Anaphylaxis due to the HiB vaccine.

Hepatitis B

Children with any of the following on or before the child’s second birthday meet criteria:

  1. 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.
  2. Anaphylaxis due to the hepatitis B vaccine.
  3. History of hepatitis B illness.
  • Vaccines are documented in Immunizations. Vaccine may be entered as Administer New or Add Historical. Enter an Order or Recorded Date for each immunization.
  • Allergic reactions to vaccines are documented under Allergies with a Start Date.
  • Illness, conditions, or history os illness is documented under Problems with a Start Date.

Varicella vaccination (VZV)

Children with either of the following meet criteria:

  1. At least one VZV vaccination, with a date of service on or between the child’s first and second birthdays.
  2. History of varicella zoster (e.g., chicken pox) illness on or before the child’s second birthday.

Pneumococcal Conjugate

  1. 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:

  1. At least one hepatitis A vaccination, with a date of service on or between the child’s first and second birthdays.
  2. History of hepatitis A illness on or before the child’s second birthday

Rotavirus

Children with any of the following meet criteria:

  1. 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.
  2. 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.
  3. 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.
  4. 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.

  1. 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.
Office Visit Documentation:

Once all steps have been completed, the measure will be added to the Quality Measures Report.

Measure type: Process
High Priority Measure: No
Telehealth Eligible: Yes
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