CMS117v7 – Childhood Immunization Status

Childhood Immunization Status CMS117v7 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 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) during the measurement period and who have a visit during the measurement period.

– DENOMINATOR EXCLUSION

Exclude patients whose hospice care overlaps 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

– APPLICATION WORKFLOW

For Denominator:

Children who turn 2 year of age during the measurement period and who have a visit during the measurement period are included in this measure. The system captures the Office visit encounters through Visit codes (E&M) which are recorded in either eSuperbills or charges.

For Numerator:

Children who have evidence showing they received all of the following criteria are included in the numerator.

  1. Administered with four doses of DTaP Vaccine or diagnosed with Anaphylactic Reaction to DTaP Vaccine
  2. Administered with three doses of Inactivated Polio Vaccine (IPV) or diagnosed with Poliomyelitis vaccine adverse reaction (disorder)
  3. Administered with one dose of Measles, Mumps and Rubella (MMR) Vaccine or diagnosed with Disorders of the Immune System
  4. Administered with three doses of Haemophilus Influenzae Type B (HiB) Vaccine or diagnosed with Anaphylaxis due to Haemophilus influenzae type b vaccine (disorder)
  5. Administered with three doses of Hepatitis B Vaccine or diagnosed with Anaphylaxis due to Hepatitis B vaccine (disorder).
  6. Administered with one dose of Varicella Zoster Vaccine (VZV) or diagnosed with Disorders of the Immune System.
  7. Administered with four doses of Pneumococcal Conjugate Vaccine or diagnosed with Pneumococcal vaccine adverse reaction (disorder).
  8. Administered with one dose of Hepatitis A Vaccine or diagnosed with Anaphylactic Reaction to Hepatitis A Vaccine.
  9. Administered with two doses of Rotavirus Vaccine (2 dose schedule) or diagnosed with Severe Combined Immunodeficiency
  10. Administered with two doses of Influenza Vaccine or diagnosed with Malignant Neoplasm of Lymphatic and Hematopoietic Tissue

To administer recommended vaccines, navigate to Patient > Clinical > Immunization.

Denominator Exclusion:

Patients who were in hospice care during the measurement year are included in denominator exclusion.

To document this, navigate to Patient > Clinical > Evaluations and use the below mentioned codes:

  • 385763009
  • 385765002