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[CMS117v4] NQF 0038 Childhood Immunization Status

Last Updated: Jul 25, 2018 01:34PM PDT
1. Measure Details.
2. Measure Parameters
3. Meeting the Measure in Elation
4. Measure Information
5. Additional Information / FAQs

1. Measure Details
Percentage of children 2 to 16 years of age who have had the following vaccines by their second birthday:
  • 4 diphtheria, tetanus and acellular pertussis (DTaP)
  • 3 polio (IPV)
  • 1 measles, mumps and rubella (MMR)
  • 3 H influenza type B (HiB)
  • 3 hepatitis B (Hep B)
  • 1 chicken pox (VZV)
  • 4 pneumococcal conjugate (PCV)
  • 1 hepatitis A (Hep A)
  • 2 or 3 rotavirus (RV)
  • 2 influenza (flu)

2. Measure Parameters:
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

Denominator: Children who turn 2 years of age during the measurement period and who have a visit during the measurement period.
Exclusions/Exceptions: None

3. Elation Workflows
1/ Ensure that each Vaccination for the patient is recorded and dated. This can be done at the point of care by adding a detailed immunization.
  • TIP= Do not select the "brand unknown" version of the vaccination because that will not be counted towards MIPS per CMS standards.

4. Measure Information

Infants and toddlers are particularly vulnerable to infectious diseases because their immune systems have not built up the necessary defenses to fight infection. Most childhood vaccines are between 90 and 99 percent effective in preventing diseases, and are a critical aspect of preventive care for children. Lack of proper immunization leads to an increase in illness, doctor visits and hospitalizations, all of which translate into higher costs. 
Immunizing a child not only protects that child's health but also the health of the community, especially for those who are not immunized or are unable to be immunized due to other health complications. When the majority of the community is immunized against a disease, other members of the community are also protected because herd immunity shields them.
5. Additional Info/FAQs
The following list contains all Vaccinations that are applicable for this measure:
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