CMS 117 - Childhood Immunization Status

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Updated: 12/09/2021
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CMS 117 / Quality ID #240

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.

Note: Each vaccine will be evaluated individually and then a combination of vaccines will be evaluated. The measure will show 12 results.

Denominator:	Children who turn 2 years of age during the measurement period and who have a visit during the measurement period. Patient’s age is calculated based on the patient’s Date of Birth, which was entered when you created the patient’s account. Create a note detailing the patient’s office visit.
Denominator Exclusions:	If patient was in Hospice during the measurement period: Hospice is documented under Hospitalizations/Procedures in History. These patients will be excluded from the denominator.
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. Vaccines: Vaccines are documented in Immunizations. Vaccine may be entered as Administer New or Add Historical. Enter an Order or Recorded Date for each immunization. Allergic reactions: Allergic reactions to vaccines are documented under Allergies with a Start Date. Illness: History of the illness is documented under Problems with a Start Date. "Positive Seropositive" test documented under Labs/Studies. The clinician will have to sign the results when received. If results are not received via eLabs, the results will have to be manually added on the order created in Labs/Studies.
Office Visit Documentation:	Enter Procedure Codes including E/M Codes or HCPCS Codes on the Superbill. Complete and sign the note. Once all steps have been completed, the measure will be added to the Quality Measures Report.
Guidance:	Patients may be included in the numerator for a particular antigen if they had an anaphylactic reaction to the vaccine. Patients may be included in the numerator for the DTaP vaccine if they have encephalopathy. Patients may be included in the numerator for the IPV vaccine if they have had an anaphylactic reaction to streptomycin, polymyxin B, or neomycin. Patients may be included in the numerator for the influenza, MMR, or VZV vaccines if they have cancer of lymphoreticular or histiocytic tissue, multiple myeloma, leukemia, have had an anaphylactic reaction to neomycin, have Immunodeficiency, or have HIV. Patients may be included in the numerator for the hepatitis B vaccine if they have had an anaphylactic reaction to common baker's yeast.
Measure type:	Process
High Priority Measure:	No
Telehealth Eligible:	Yes