CMS 117/MIPS 240 - Childhood Immunization Status

What is this Measure?

This measure tracks is a clinical quality measure (CQM) used to assess whether children receive recommended vaccines by their second birthday.

Measure Overview

• Population: Children who turn 2 years old during the measurement period.

• Denominator: All children who have a visit and turn 2 within the measurement period.

Populating the Denominator:

All children who have a visit and turn 2 within the measurement period.

1. Step 1: Input Patient Birthdate

2. Step 2: Enter date, Encounter Type and Provider

3. Step 3: Enter procedure code

• Applicable Codes:

SNOMEDCT:

1162640003, 16290681000119103, 16298561000119108, 310306005, 310307001, 310308006, 312870000, 313383003, 390846000, 390865008, 399014008, 412755006, 412756007, 412757003, 412762002, 412763007, 412764001, 414001002, 414259000, 414620004, 415507003, 415712004, 428251000124104, 571571000119105, 572561000119108, 770608009, 770616000, 770617009, 770618004, 787436003, 866158005, 866159002, 866226006, 868273007, 868274001, 868276004, 868277008, 310306005, 310307001, 310308006, 312870000, 414001002, 414259000, 415507003, 415712004        

CPT:

99202, 90697, 90698, 90700, 90723,  

0644, 90648, 90698

Populating the Numerator:

Children who have received all the following vaccinations by their second birthday.

1. Step 1: Enter an Immunization

• 4 DTaP (Diphtheria, Tetanus, and Acellular Pertussis)

• 3 IPV (Polio)

• 1 MMR (Measles, Mumps, and Rubella)

• 3 Hib (Haemophilus influenzae type B)

• 3 Hepatitis B

• 1 Varicella (Chickenpox)

• 4 PCV (Pneumococcal Conjugate Vaccine)

• 1 Hepatitis A

• 2 or 3 Rotavirus (depending on the vaccine used)

• 2 Influenza

2. Step 2: Populate Dtap/Hib vaccine procedure code

• Dtap SNOMEDCT:

1162640003, 16290681000119103, 16298561000119108, 310306005, 310307001, 310308006, 312870000, 313383003, 390846000, 390865008, 399014008, 412755006, 412756007, 412757003, 412762002, 412763007, 412764001, 414001002, 414259000, 414620004, 415507003, 415712004, 428251000124104, 571571000119105, 572561000119108, 770608009, 770616000, 770617009, 770618004, 787436003, 866158005, 866159002, 866226006, 868273007, 868274001, 868276004, 868277008

Dtap CPT:

90697, 90698, 90700, 90723

Purpose

The goal is to encourage timely childhood immunization and prevent outbreaks of vaccine-preventable diseases. The measure reflects adherence to the CDC’s Advisory Committee on Immunization Practices (ACIP) recommendations.

Exclusions

• Children with medical contraindications or documented vaccine allergies.

• Those who die or are in hospice before age two.

• Children who were never seen during the measurement period.

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