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.
– DENOMINATOR EXCLUSION
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.
– APPLICATION WORKFLOW
For Denominator:
All children who turn 2 years of age during the measurement period and who have a qualifying encounter during the measurement period. To record an encounter, navigate to Patient > Provider Note > eSuperbill. Under the ‘Procedures- CPTs’ heading, enter the encounter code.
Home Healthcare Services
Preventive Care Services-Initial Office Visit, 0 to 17
Preventive Care Services – Established Office Visit, 0 to 17
Office Visit
Online Assessments
Telephone Visits
eSuperbill
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/Encephalopathy due to Childhood Vaccination.
The DTaP conditions should be diagnosed within the two years after the child’s birth date. To record the Anaphylactic Reaction to DTaP Vaccine/Encephalopathy due to Childhood Vaccination diagnosis, use the workflow Patient > Provider Note > Diagnoses, and click ‘Add’. Search for the diagnosis and add the diagnosis details. Then click ‘Save’. The diagnosis is added to the provider note.
Diagnosis
The DTaP immunizations or vaccine procedures should be recorded within the interval of forty-two days and two years after the child’s birth date. The successive vaccinations should be administered 1 day or more apart. To document DTaP immunization, use the workflow Patient > Clinical > Immunization. Click ‘+ Dosage’ and select ‘Administer Vaccine’ and the DTaP vaccine category. In the vaccine search window, search for the DTaP vaccine. Complete the vaccine details and click ‘Save’.
DTaP Immunization
To document DTaP vaccination procedure, navigate to Patient > Provider Note > Orders > Procedures. Click ‘Add’ and search for the procedure. Add the procedure details and click on ‘Save & Accept’/hover over ‘Sign & Accept’. If the user hovers over ‘Sign & Accept’, then click ‘Complete’.
DTaP Vaccination Procedure
Note:
Please ensure that the Procedure is present in the system. For this, navigate to Settings > Billing > Procedure. If the procedure is not added then, click on the ‘Add Procedure’ button.
Add Procedure
Here, enter the ‘Code’ and ‘Name’ of the Procedure. Once done, click on the ‘Save’ button.
Add Procedure
2. Administered with three doses of Inactivated Polio Vaccine (IPV) or diagnosed with Polio Numerator Inclusion Conditions
The polio conditions should be diagnosed within the two years after the child’s birth date. To record the diagnosis, use the workflow Patient > Provider Note > Diagnoses, and click ‘Add’. Search for the diagnosis and add the diagnosis details. Then click ‘Save’. The diagnosis is added to the provider note.
The IPV immunizations or vaccine procedures should be recorded within the interval of forty-two days and two years after the child’s birth date. The successive vaccinations should be administered 1 day or more apart. To document IPV immunization, use the workflow Patient > Clinical > Immunization. Click ‘+ Dosage’ and select ‘Administer Vaccine’ and the IPV vaccine category. In the vaccine search window, search for the IPV vaccine. Complete the vaccine details and click ‘Save’.
To document IPV vaccination procedure, navigate to Patient > Provider Note > Orders > Procedures. Click ‘Add’ and search for the procedure. Add the procedure details and click on ‘Save & Accept’/hover over ‘Sign & Accept’. If the user hovers over ‘Sign & Accept’, then click ‘Complete’.
3. Administered with 3 or 4 doses of Haemophilus Influenzae Type B (Hib) Immunizations or diagnosed with Hib reaction.
The Hib reaction should be diagnosed within the two years after the child’s birth date. To record the diagnosis, use the workflow Patient > Provider Note > Diagnoses, and click ‘Add’. Search for the diagnosis and add the diagnosis details. Then click ‘Save’. The diagnosis is added to the provider note.
The Hib immunizations or vaccine procedures should be recorded within the interval of forty-two days and two years after the child’s birth date. To document Hib immunization, use the workflow Patient > Clinical > Immunization. Click ‘+ Dosage’ and select ‘Administer Vaccine’ and the Hib vaccine category. In the vaccine search window, search for the Hib vaccine. Complete the vaccine details and click ‘Save’.
To document Hib vaccination procedure, navigate to Patient > Provider Note > Orders > Procedures. Click ‘Add’ and search for the procedure. Add the procedure details and click on ‘Save & Accept’/hover over ‘Sign & Accept’. If the user hovers over ‘Sign & Accept’, then click ‘Complete’.
4. Administered with three doses of Hepatitis B Vaccine or diagnosed with Hepatitis B Numerator Inclusion Conditions.
The Hepatitis B conditions should be diagnosed within the two years after the child’s birth date. To record a diagnosis, use the workflow Patient > Provider Note > Diagnoses, and click ‘Add’. Search for the diagnosis and add the diagnosis details. Then click ‘Save’. The diagnosis is added to the provider note.
To record ‘Anti Hepatitis B Virus Surface Ab’ laboratory test, navigate to Patient > Clinical > Orders & Result > Labs and click on the ‘+ Add Order’ button. Select a Laboratory and search for a ‘Anti Hepatitis B Virus Surface Ab’ test. Once done, click on the ‘Save’ button or hover over the ‘Sign’ button. If the user hovers over the ‘Sign’ button, then click ‘Queue’.
‘Anti Hepatitis B Virus Surface Ab’ Test
Next, click on the ‘Mark As Received’ button.
‘Mark As Received’ Button
On the lab result screen, add the observations and click on the ‘Save’ button.
Save Button
Note:
For LOINC Code Based Labs: Please ensure that the lab code is mapped to a LOINC Code from the Settings. To map a LOINC with the lab code, navigate to Settings > EHR > Laboratory. Select the Lab and navigate to the ‘Code’ tab. Then, click on the Lab Order. Under the ‘Result Codes and LOINCS’ heading, add a Code, LOINC and Description and click on the ‘Add’ button. Once done, click on ‘Save’.
Laboratory – Settings
For CPT Code Based Labs: When a CPT code is added to a lab order, please ensure that the CPT code is present in the ‘Procedures’.
CPT Codes
Moreover, the CPT code should be mapped to a LOINC Code from the Settings. To map a LOINC with the CPT code, navigate to Settings > Billing > Procedure. Select the CPT code and navigate to the ‘Edit Procedure’ tab. Under the ‘Procedure Components’ heading, add a Code, LOINC and Description and click on the ‘Add’ button.
Once done, click on ‘Save’.
Procedure Components
The Hepatitis B immunizations or vaccine procedures should be recorded within two years after the child’s birth date. The successive vaccinations should be administered 1 day or more apart. To document Hepatitis B immunization, use the workflow Patient > Clinical > Immunization. Click ‘+ Dosage’ and select ‘Administer Vaccine’ and the Hepatitis B vaccine category. In the vaccine search window, search for the Hepatitis B vaccine. Complete the vaccine details and click ‘Save’.
To document Hepatitis B vaccination procedure, navigate to Patient > Provider Note > Orders > Procedures. Click ‘Add’ and search for the procedure. Add the procedure details and click on ‘Save & Accept’/hover over ‘Sign & Accept’. If the user hovers over ‘Sign & Accept’, then click ‘Complete’.
5. Administered with one dose of Measles, Mumps and Rubella (MMR) Vaccine or diagnosed with MMR Numerator Inclusion Conditions or has evidence of MMR indicators
The MMR conditions should be diagnosed within the two years after the child’s birth date. To record the diagnosis, use the workflow Patient > Provider Note > Diagnoses, and click ‘Add’. Search for the diagnosis and add the diagnosis details. Then click ‘Save’. The diagnosis is added to the provider note.
The MMR immunizations or vaccine procedures should be recorded within the interval of forty-two days and two years after the child’s birth date. The successive vaccinations should be administered 1 day or more apart. To document MMR immunization, use the workflow Patient > Clinical > Immunization. Click ‘+ Dosage’ and select ‘Administer Vaccine’ and the MMR vaccine category. In the vaccine search window, search for the MMR vaccine. Complete the vaccine details and click ‘Save’.
To document MMR vaccination procedure, navigate to Patient > Provider Note > Orders > Procedures. Click ‘Add’ and search for the procedure. Add the procedure details and click on ‘Save & Accept’/hover over ‘Sign & Accept’. If the user hovers over ‘Sign & Accept’, then click ‘Complete’.
The diagnoses for measles, mumps or rubella should be recorded within the two years after the child’s birth date. To record a diagnosis, use the workflow Patient > Provider Note > Diagnoses, and click ‘Add’. Search for the diagnosis and add the diagnosis details. Then click ‘Save’. The diagnosis is added to the provider note.
To record a laboratory test for MMR, navigate to Patient > Clinical > Orders & Result > Labs and click on the ‘+ Add Order’ button. Select a Laboratory and search for a laboratory test. Once done, click on the ‘Save’ button or hover over the ‘Sign’ button. If the user hovers over the ‘Sign’ button, then click ‘Queue’. Next, click on the ‘Mark As Received’ button. On the lab result screen, add the observations and click on the ‘Save’ button.
6. Administered with one dose of Chicken Pox Vaccination or diagnosed with Varicella Zoster Numerator Inclusion Conditions.
The varicella zoster conditions should be diagnosed within the two years after the child’s birth date. To record a diagnosis, use the workflow Patient > Provider Note > Diagnoses, and click ‘Add’. Search for the diagnosis and add the diagnosis details. Then click ‘Save’. The diagnosis is added to the provider note.
To record ‘Varicella Zoster Antibody Test (IgG Antibody Titer)/ (IgG Antibody Presence)’ laboratory test, navigate to Patient > Clinical > Orders & Result > Labs and click on the ‘+ Add Order’ button. Select a Laboratory and search for a laboratory test. Once done, click on the ‘Save’ button or hover over the ‘Sign’ button. If the user hovers over the ‘Sign’ button, then click ‘Queue’. Next, click on the ‘Mark as received’ button. On the lab result screen, add the observations and click on the ‘Save’ button.
The chicken pox immunization or vaccine procedure should be recorded within two years after the child’s birth date. To document chicken pox immunization, use the workflow Patient > Clinical > Immunization. Click ‘+ Dosage’ and select ‘Administer Vaccine’ and the chicken pox vaccine category. In the vaccine search window, search for the chicken pox vaccine. Complete the vaccine details and click ‘Save’.
To document chicken pox vaccination procedure, navigate to Patient > Provider Note > Orders > Procedures. Click ‘Add’ and search for the procedure. Add the procedure details and click on ‘Save & Accept’/hover over ‘Sign & Accept’. If the user hovers over ‘Sign & Accept’, then click ‘Complete’.
7. Administered with four doses of Pneumococcal Conjugate Vaccinations or diagnosed with Pneumococcal Reaction.
The pneumococcal reaction should be diagnosed within the two years after the child’s birth date. To record the diagnosis, use the workflow Patient > Provider Note > Diagnoses, and click ‘Add’. Search for the diagnosis and add the diagnosis details. Then click ‘Save’. The diagnosis is added to the provider note.
The pneumococcal conjugate immunizations or vaccine procedures should be recorded within the interval of forty-two days and two years after the child’s birth date. The successive vaccinations should be administered 1 day or more apart. To document pneumococcal conjugate immunization, use the workflow Patient > Clinical > Immunization. Click ‘+ Dosage’ and select ‘Administer Vaccine’ and the pneumococcal conjugate vaccine category. In the vaccine search window, search for the pneumococcal conjugate Complete the vaccine details and click ‘Save’.
To document pneumococcal conjugate vaccination procedure, navigate to Patient > Provider Note > Orders > Procedures. Click ‘Add’ and search for the procedure. Add the procedure details and click on ‘Save & Accept’/hover over ‘Sign & Accept’. If the user hovers over ‘Sign & Accept’, then click ‘Complete’.
8. Administered with one dose of Hepatitis A Vaccine or diagnosed with Anaphylactic Reaction to Hepatitis A Vaccine/Hepatitis A.
The Hepatitis A conditions should be diagnosed within the two years after the child’s birth date. To record the Anaphylactic Reaction to Hepatitis A Vaccine/Hepatitis A diagnosis, use the workflow Patient > Provider Note > Diagnoses, and click ‘Add’. Search for the diagnosis and add the diagnosis details. Then click ‘Save’. The diagnosis is added to the provider note.
To record ‘Anti Hepatitis A IgG Antigen’ laboratory test, navigate to Patient > Clinical > Orders & Result > Labs and click on the ‘+ Add Order’ button. Select a Laboratory and search for a ‘Anti Hepatitis A IgG Antigen’ test. Once done, click on the ‘Save’ button or hover over the ‘Sign’ button. If the user hovers over the ‘Sign’ button, then click ‘Queue’. Next, click on the ‘Mark as received’ button. On the lab result screen, add the observations and click on the ‘Save’ button.
The Hepatitis A immunization or vaccine procedure should be recorded within two years after the child’s birth date. To document influenza immunization, use the workflow Patient > Clinical > Immunization. Click ‘+ Dosage’ and select ‘Administer Vaccine’ and the Hepatitis A vaccine category. In the vaccine search window, search for the Hepatitis vaccine. Complete the vaccine details and click ‘Save’.
To document Hepatitis A vaccination procedure, navigate to Patient > Provider Note > Orders > Procedures. Click ‘Add’ and search for the procedure. Add the procedure details and click on ‘Save & Accept’/hover over ‘Sign & Accept’. If the user hovers over ‘Sign & Accept’, then click ‘Complete’.
9. Administered with 2 or 3 doses of Rotavirus Immunizations or diagnosed with Rotavirus Numerator Inclusion Conditions
The rotavirus conditions should be diagnosed within the two years after the child’s birth date. To record the diagnosis, use the workflow Patient > Provider Note > Diagnoses, and click ‘Add’. Search for the diagnosis and add the diagnosis details. Then click ‘Save’. The diagnosis is added to the provider note.
The rotavirus immunizations or vaccine procedures should be recorded within the interval of forty-two days and two years after the child’s birth date. To document rotavirus immunization, use the workflow Patient > Clinical > Immunization. Click ‘+ Dosage’ and select ‘Administer Vaccine’ and the rotavirus vaccine category. In the vaccine search window, search for the rotavirus vaccine. Complete the vaccine details and click ‘Save’.
To document rotavirus vaccination procedure, navigate to Patient > Provider Note > Orders > Procedures. Click ‘Add’ and search for the procedure. Add the procedure details and click on ‘Save & Accept’/hover over ‘Sign & Accept’. If the user hovers over ‘Sign & Accept’, then click ‘Complete’.
10. Administered with two doses of Influenza Vaccinations or or two doses of influenza Vaccinations Including One LAIV Vaccination or diagnosed with Influenza Numerator Inclusion Conditions
The influenza conditions should be diagnosed within the two years after the child’s birth date. To record the diagnosis, use the workflow Patient > Provider Note > Diagnoses, and click ‘Add’. Search for the diagnosis and add the diagnosis details. Then click ‘Save’. The diagnosis is added to the provider note.
The influenza immunizations or vaccine procedures should be recorded within the interval of one-eighty days and two years after the child’s birth date. The successive vaccinations should be administered 1 day or more apart. To document influenza immunization, use the workflow Patient > Clinical > Immunization. Click ‘+ Dosage’ and select ‘Administer Vaccine’ and the influenza vaccine category. In the vaccine search window, search for the influenza vaccine. Complete the vaccine details and click ‘Save’.
To document influenza vaccination procedure, navigate to Patient > Provider Note > Orders > Procedures. Click ‘Add’ and search for the procedure. Add the procedure details and click on ‘Save & Accept’/hover over ‘Sign & Accept’. If the user hovers over ‘Sign & Accept’, then click ‘Complete’.
The influenza virus LAIV immunization or procedure should be recorded on the date of second birthday. To document influenza virus LAIV immunization, use the workflow Patient > Clinical > Immunization. To document influenza virus LAIV procedure, navigate to Patient > Provider Note > Orders > Procedures.
For Denominator Exclusion:
Patients who received hospice care during the measurement year are excluded from the denominator. To document that patient is receiving hospice care outside of a hospital or long term care facility, navigate to Patient > Clinical > Evaluations. Click ‘+Evaluation’ and search for an intervention. Then click ‘Sign’ or ‘Save’.
385763009: Hospice Care (Regime/Therapy)
385765002: Hospice Care Management (Procedure)
Evaluation
To document an encounter inpatient, navigate to Patient > Clinical > Evaluations
