CMS117v6 – Childhood Immunization Status

Childhood Immunization Status CMS117v6 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 of age during the measurement period and who have a visit during the measurement period are included in the denominator. The system captures the Office visit encounters through Visit codes (E&M) which are recorded in either eSuperbills or charges.

– DENOMINATOR EXCLUSION

Exclude patients who were in hospice care during the measurement year.

– NUMERATOR

Children who have one of the following:

  • Received recommended vaccines
  • Had documented history of the illness
  • Had a seropositive test result
  • Had an allergic reaction to the vaccine by their second birthday
– APPLICATION WORKFLOW

For Denominator:

Children who turn 2 years 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.

First Visit

Denominator Exclusion:

To exclude patients patients who were in hospice care during the measurement year, navigate to Patient > Clinical > Evaluations

Denominator Exclusion

For Numerator:

Children who have evidence showing they received any one of the following:

  • Recommended vaccines (Patient > Clinical > Immunization)

    1. Immunization, Administered: Four doses of DTaP Vaccine
    2. Immunization, Administered: Three doses of Inactivated Polio Vaccine (IPV)
    3. Immunization, Administered: One dose of Measles, Mumps and Rubella (MMR) Vaccine
    4. Immunization, Administered: Three doses of Haemophilus Influenzae Type B (HiB) Vaccine
    5. Immunization, Administered: Three doses of Hepatitis B Vaccine
    6. Immunization, Administered: One dose of Varicella Zoster Vaccine (VZV)
    7. Immunization, Administered: Four doses of Pneumococcal Conjugate Vaccine
    8. Immunization, Administered: One dose of Hepatitis A Vaccine
    9. Immunization, Administered: Two doses of Rotavirus Vaccine (2 dose schedule)
    10. Immunization, Administered: Two doses of Influenza Vaccine

Immunization
  • Had documented history of the illness (Patient > Clinical > Diagnosis)
  1. Anaphylactic Reaction to Influenza Vaccine
  2. Malignant Neoplasm of Lymphatic and Hematopoietic Tissue
  3. Anaphylactic Reaction to Neomycin
  4. HIV
  5. Disorders of the Immune System
  • Had a seropositive test result (Patient > Clinical > Orders and Results > Lab > Add Result)
  1. These are the Lab tests for any of the following:
  2. Measles, Mumps and Rubella (MMR) Vaccine
  3. Hepatitis B Vaccine
  4. Varicella Zoster Vaccine (VZV)
  5. Hepatitis A Vaccine
  6. Influenza Vaccine
  7. Rubella Virus
  8. Mumps Virus
  • Had an allergic reaction to the vaccine by their second birthday are included in the numerator. To record a vaccine or diagnosis, navigate to (Patient > Clinical > Allergies)

Diagnosis and Vaccine