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      CMS117v13: Childhood Immunization Status

      Percentage of children 2 years of age who had the appropriate vaccinations added by their second birthday

      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

      Numerator

      Patients will qualify for the numerator when they have met all of the following conditions:

      All Vaccines need to be entered into the Clinical Decision Support section of the Most Recent Encounter. Free Text vaccines will not count.

      • Diphtheria, tetanus, and pertussis (DTaP) vaccination: Children with any of the following on or before the child’s second birthday meet criteria:
        • At least four DTaP vaccinations, with different dates of service. A vaccination administered prior to 42 days after birth will not count
        • Anaphylaxis due to the diphtheria, tetanus or pertussis vaccine.
        • Encephalitis due to the diphtheria, tetanus or pertussis vaccine.
      • Poliovirus vaccination (IPV): Children with either of the following on or before the child’s second birthday meet criteria:
        • At least three IPV vaccinations, with different dates of service. A vaccination administered prior to 42 days after birth do not count.
        • Anaphylaxis due to the IPV vaccine
      • Measles, mumps, and rubella vaccination (MMR): Children with any of the following meet criteria:
        • At least one MMR vaccination on or between the child’s first and second birthdays.
        • 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
          • Anaphylaxis due to the MMR vaccine on or before the child’s second birthday
      • Haemophilus influenzae type b vaccination (HiB): Children with either of the following meet criteria on or before the child’s second birthday:
        • At least three HiB vaccinations, with different dates of service. A vaccination administered prior to 42 days after birth do not count.
        • Anaphylaxis due to the HiB vaccine.
      • Hepatitis B: Children with any of the following on or before the child’s second birthday meet criteria:
        • 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.
        • Anaphylaxis due to the hepatitis B vaccine.
        • History of hepatitis B illness.
      • Varicella vaccination (VZV): Children with any of the following meet criteria:
        • At least one VZV vaccination, with a date of service on or between the child’s first and second birthdays.
        • History of varicella zoster (e.g., chicken pox) illness on or before the child’s second birthday.
        • Anaphylaxis due to the VZV vaccine on or before the child’s second birthday
      • Pneumococcal Conjugate Vaccination (PCV): Children with either of the following on or before the child’s second birthday meet criteria:
        • At least four pneumococcal conjugate vaccinations, with different dates of service on or before the child’s second birthday. A vaccination administered prior to 42 days after birth do not count.
        • Anaphylaxis due to the pneumococcal vaccine.
      • Hepatitis A: Children with any of the following meet criteria:
        • At least one hepatitis A vaccination, with a date of service on or between the child’s first and second birthdays.
        • History of hepatitis A illness on or before the child’s second birthday.
        • Anaphylaxis due to the hepatitis A vaccine on or before the child’s second birthday
      • Rotavirus: Children with any of the following meet criteria:
        • At least two doses of the two-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. A vaccination administered prior to 42 days after birth do not count
        • At least three doses of the three-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. A vaccination administered prior to 42 days after birth do not count.
        • 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. A vaccination administered prior to 42 days after birth do not count.
        • Anaphylaxis due to the rotavirus vaccine on or before the child’s second birthday.
      • Influenza: Children with either of the following on or before their second birthday meet criteria:
        • At least two influenza vaccinations, with different dates of service on or before the child’s second birthday. A vaccination administered prior to 6 months (180 days) after birth do not count.
        • One of the two vaccinations can be a Live Attenuated Influenza Vaccine (LAIV) vaccination administered on the child’s second birthday. A LAIV vaccination administered before the child’s second birthday does not count.
        • Anaphylaxis due to the influenza vaccine

       

      Note: Immunizations given elsewhere (and marked as such in the Immunizations screen) do count for this measure, but immunizations that the patient refuses do not.

      Denominator

      Children who turn 2 years of age during the measurement period and have an encounter during the measurement period.

      Exclusions

      • Exclude children with any of the following diagnosis on or before the child’s second birthday:
        • Severe combined immunodeficiency
        • Immunodeficiency
        • HIV
        • Lymphoreticular cancer, multiple myeloma or leukemia
        • Intussusception

      • Exclude children whose hospice or palliative care overlaps the measurement period:

        • Identified in the patient's Alerts and Directives, located in the demographic screen or the Summary Sheet, in the name, text or comments saved with that alert/directive. The Alert/Directive should include either of the following phrases:
          • palliative
          • hospice