NQF 0038 (Alternate Core) - Childhood Immunization Status

Measure: NQF 0038 (Alternate Core Measure)

Measure Title: Childhood Immunization Status

Measure Description: 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); two H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); two hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates.

Quality Measure Documentation Workflow

In Order for the Clinical Quality Measure report to generate, the following must be documented in the relevant patient's chart:

1.  The patient age must be >=1 year and <2 years and have at least 1 face to face encounter during the reporting period.

2.  Documentation of immunizations (Dtap, IPV, MMR, Hib, HepB, HepA, VZV, Pneumococcal, Rotavirus, Influenza) documented in the encounter Plan field using SMARText Plan Items or Immunization Order Entry items in SOAPware Order Manager.

Searching for Immunization Items in SMARText

Searching for Immunization Items in SMARText

The Immunization Order SMARText Item types can be used to meet this criteria requirements (SMARText Plan Items are also acceptable).  These Items can be downloaded to a users local database using the following steps:

  1. To find  the SMARText Immunizations Order item types, type the keyword, "cvxi' into the search field of the SMARText Manager (press F10 to access).
  2. Press and hold the Shift key on the keyboard and then highlight the items to be used.
  3. Click on the Download button to bring the items into the local database.

For more information on entering Immunization items using Order Manager, see: Immunization Order Items.

Measure Calculation Details

Eligible Providers will be required to report 12 population criteria for this measure:

Population Criteria #1: >= 4 counts of DTaP vaccine

Numerator Calculation:

  1. The number of patients in the denominator that have >= 4 counts of DTaP vaccine recorded in the SOAPnote Plan field; occurring >=42 days and <2 years after the patients birth date.  The DTaP vaccine can be recorded in the SOAPnote Plan field by using the following codes:
  • c90721oi: DTAP-HIB VACCINE, IM (CVX code 50)
  • c90723oi: DTAP-HEP B-IPV, IM (CVX code 110)
  • c90696oi: DTAP-IPV VACC, 4-6 YR, IM (CVX code 130)
  • c90698oi: DTAP-HIB-IP VACCINE, IM (CVX code 120)
  • c90700oi: DTAP VACCINE, <7 YRS, IM or DTAP 5 PERTUSS ANT VACC, <7 YRS, IM (CVX code 20)

Denominator Calculation:

  1. The number of patients who are age >=1 year and <2 years and have at least one face-to-face encounter during the reporting period.

Population Criteria #2: >=3 counts of IPV vaccine

Numerator Calculation:

  1. The number of patients in the denominator that have >=3 counts of IPV vaccine recorded in the SOAPnote Plan field; occurring >=42 days and <2 years after the patients birth date.  The IPV vaccine can be recorded in the SOAPnote Plan field by using the following codes:
  • c90696oi: DTAP-IPV VACC, 4-6 YR, IM (CVX code 130)
  • c90698oi: DTAP-HIB-IP VACCINE, IM (CVX code 120)
  • c90713oi: POLIOVIRUS, IPV, SC/IM (CVX code 10)
  • c90723oi: DTAP-HEP B-IPV, IM (CVX code 110)

Denominator Calculation:

  1. The number of patients who are age >=1 year and <2 years and have at least one face-to-face encounter during the reporting period.

Population Criteria #3: >=1 counts of MMR vaccine

Numerator Calculation:

  1. The number of patients in the denominator that have >=1 counts of MMR vaccine recorded in the SOAPnote Plan field; occurring <2 years after the patients birth date.  The MMR vaccine can be recorded in the SOAPnote Plan field by using the following codes:
  • c90707oi: MMR VACCINE, SC (CVX code 03)
  • c90710oi: MMRV VACC, SC (CVX code 94)

Denominator Calculation:

  1. The number of patients who are age >=1 year and <2 years and have at least one face-to-face encounter during the reporting period.

Population Criteria #4: >=2 counts of HiB vaccine

Numerator Calculation:

  1. The number of patients in the denominator that have >=2 counts of HiB vaccine recorded in the SOAPnote Plan field; occurring >=42 days and <2 years after the patients birth date.  The HiB vaccine can be recorded in the SOAPnote Plan field by using the following codes:
  • c90645oi: HIB VACCINE, HBOC, IM (CVX code 47)
  • c90646oi: HIB VACCINE, PRP-D IM (CVX code 46)
  • c90647oi: HIB VACCINE, PRP-OMP, IM (CVX code 49)
  • c90648oi: HIB PRP-T, IM (CVX code 48)
  • c90698oi: DTAP-HIB-IP VACCINE, IM (CVX code 120)
  • c90720oi: DTP/HIB VACCINE, IM (CVX code 22)
  • c90721oi: DTAP-HIB VACCINE, IM (CVX code 50)
  • c90748oi: HEP B/HIB VACCINE, IM (CVX code 51)

Denominator Calculation:

  1. The number of patients who are age >=1 year and <2 years and have at least one face-to-face encounter during the reporting period.

Population Criteria #5: >=3 counts of Hepatitis B vaccine

Numerator Calculation:

  1. The number of patients in the denominator that have >=3 counts of Hepatitis B vaccine recorded in the SOAPnote Plan field; occurring <2 years after the patients birth date.  The Hepatitis B vaccine can be recorded in the SOAPnote Plan field by using the following codes:
  • c90636oi: HEP A/HEP B VACCINE, ADULT, IM (CVX code 104)
  • c90723oi: DTAP-HEP B-IPV, IM (CVX code 110)
  • c90747oi: HEPB VACC, ILL PAT 4-D IM (CVX code 44)
  • c90740oi: HEPB VACC, ILL PAT 3-D IM (CVX code 44)
  • c90746oi: HEP B VACCINE, ADULT, IM (CVX code 43)
  • c90743oi: HEP B VACC, ADOL, 2 DOSE, IM (CVX code 43)
  • c90748oi: HEP B/HIB VACCINE, IM (CVX code 51)

OR

  1. Diagnosis resolved: Hepatitis B diagnosis in the Summary Inactive Problems field using one of the following ICD9 codes:
  • 070.2, 070.3, V02.61

Denominator Calculation:

  1. The number of patients who are age >=1 year and <2 years and have at least one face-to-face encounter during the reporting period.

Population Criteria #6: >=1 counts of VZV vaccine

Numerator Calculation:

  1. The number of patients in the denominator that have >=1 counts of VZV vaccine recorded in the SOAPnote Plan field; occurring <2 years after the patients birth date.  The VZV vaccine can be recorded in the SOAPnote Plan field by using the following codes:
  • c90710oi: MMRV VACC, SC (CVX code 94)
  • c90716oi: CHICKEN POX VACCINE, SC (CVX code 21)

OR

  1. Diagnosis resolved: VZV diagnosis in the Summary Inactive Problems field using one of the following ICD9 codes:
  • 052, 053

Denominator Calculation:

  1. The number of patients who are age >=1 year and <2 years and have at least one face-to-face encounter during the reporting period.

Population Criteria #7: >=4 counts of Pneumococcal vaccine

Numerator Calculation:

  1. The number of patients in the denominator that have >=4 counts of Pneumococcal vaccine recorded in the SOAPnote Plan field; occurring >=42 days and <2 years after the patients birth date.  The Pneumococcal vaccine can be recorded in the SOAPnote Plan field by using the following codes:
  • c90669oi: PNEUMOCOCCAL VACC, PED <5 (CVX code 100)
  • c90670oi: PNEUMOCOCCAL VACC, 13 VAL IM (CVX code 133)

Denominator Calculation:

  1. The number of patients who are age >=1 year and <2 years and have at least one face-to-face encounter during the reporting period.

Population Criteria #8: >=2 counts of Hepatitis A vaccine

Numerator Calculation:

  1. The number of patients in the denominator that have >=2 counts of Hepatitis A vaccine recorded in the SOAPnote Plan field; occurring <2 years after the patients birth date.  The Hepatitis A vaccine can be recorded in the SOAPnote Plan field by using the following codes:
  • c90633oi: HEP A VACC, PED/ADOL, 2 DOSE (CVX code 83)
  • c90634oi: HEP A VACC PED/ADOL 3 DOSE, IM (CVX code 84)

OR

  1. Diagnosis resolved: Hepatitis A diagnosis in the Summary Inactive Problems field using one of the following ICD9 codes:
  • 070.0, 070.1

Denominator Calculation:

  1. The number of patients who are age >=1 year and <2 years and have at least one face-to-face encounter during the reporting period.

Population Criteria #9: >=2 counts of Rotavirus vaccine

Numerator Calculation:

  1. The number of patients in the denominator that have >=2 counts of Rotavirus vaccine recorded in the SOAPnote Plan field; occurring >=42 days and <2 years after the patients birth date.  The Rotavirus vaccine can be recorded in the SOAPnote Plan field by using the following codes:
  • c90680oi: ROTOVIRUS VACC 3 DOSE, ORAL (CVX code 116)
  • c90681oi: ROTOVIRUS VACC 2 DOSE, ORALS (CVX code 19)

Denominator Calculation:

  1. The number of patients who are age >=1 year and <2 years and have at least one face-to-face encounter during the reporting period.

Population Criteria #10: >=2 counts of Influenza vaccine

Numerator Calculation:

  1. The number of patients in the denominator that have >=2 counts of Influenza vaccine recorded in the SOAPnote Plan field; occurring >=180 days and <2 years after the patients birth date.  The Influenza vaccine can be recorded in the SOAPnote Plan field by using the following codes:
  • c90655oi: FLU VACCINE NO PRESERV 6-35M (CVX code 140)
  • cQ2039oi: FLU VACCINE, 3 YRS & >, IM (CVX code 141)
  • c90657oi: FLU VACCINE, 3 YRS, IM (CVX code 141)
  • c90660oi: FLU VACCINE, NASAL (CVX code 111)

Denominator Calculation:

  1. The number of patients who are age >=1 year and <2 years and have at least one face-to-face encounter during the reporting period.

Population Criteria #11: DTaP, IPV, MMR, VZV, Hepatitis B vaccines

Numerator Calculation:

1.  DTaP: The number of patients in the denominator that have >= 4 counts of DTaP vaccine recorded in the SOAPnote Plan field; occurring >=42 days and <2 years after the patients birth date.  The DTaP vaccine can be recorded in the SOAPnote Plan field by using the following codes:

  • c90721oi: DTAP-HIB VACCINE, IM (CVX code 50)
  • c90723oi: DTAP-HEP B-IPV, IM (CVX code 110)
  • c90696oi: DTAP-IPV VACC, 4-6 YR, IM (CVX code 130)
  • c90698oi: DTAP-HIB-IP VACCINE, IM (CVX code 120)
  • c90700oi: DTAP VACCINE, <7 YRS, IM or DTAP 5 PERTUSS ANT VACC, <7 YRS, IM (CVX code 20)

2.  IPV: The number of patients in the denominator that have >=3 counts of IPV vaccine recorded in the SOAPnote Plan field; occurring >=42 days and <2 years after the patients birth date.  The IPV vaccine can be recorded in the SOAPnote Plan field by using the following codes:

  • c90696oi: DTAP-IPV VACC, 4-6 YR, IM (CVX code 130)
  • c90698oi: DTAP-HIB-IP VACCINE, IM (CVX code 120)
  • c90713oi: POLIOVIRUS, IPV, SC/IM (CVX code 10)
  • c90723oi: DTAP-HEP B-IPV, IM (CVX code 110)

3.  MMR: The number of patients in the denominator that have >=1 counts of MMR vaccine recorded in the SOAPnote Plan field; occurring <2 years after the patients birth date.  The MMR vaccine can be recorded in the SOAPnote Plan field by using the following codes:

  • c90707oi: MMR VACCINE, SC (CVX code 03)
  • c90710oi: MMRV VACC, SC (CVX code 94)

4. VZV: The number of patients in the denominator that have >=1 counts of VZV vaccine recorded in the SOAPnote Plan field; occurring <2 years after the patients birth date.  The VZV vaccine can be recorded in the SOAPnote Plan field by using the following codes:

  • c90710oi: MMRV VACC, SC (CVX code 94)
  • c90716oi: CHICKEN POX VACCINE, SC (CVX code 21)

5. Hepatitis B: The number of patients in the denominator that have >=3 counts of Hepatitis B vaccine recorded in the SOAPnote Plan field; occurring <2 years after the patients birth date.  The Hepatitis B vaccine can be recorded in the SOAPnote Plan field by using the following codes:

  • c90636oi: HEP A/HEP B VACCINE, ADULT, IM (CVX code 104)
  • c90723oi: DTAP-HEP B-IPV, IM (CVX code 110)
  • c90747oi: HEPB VACC, ILL PAT 4-D IM (CVX code 44)
  • c90740oi: HEPB VACC, ILL PAT 3-D IM (CVX code 44)
  • c90746oi: HEP B VACCINE, ADULT, IM (CVX code 43)
  • c90743oi: HEP B VACC, ADOL, 2 DOSE, IM (CVX code 43)
  • c90748oi: HEP B/HIB VACCINE, IM (CVX code 51)

OR

Diagnosis resolved: Hepatitis B diagnosis in the Summary Inactive Problems field using one of the following ICD9 codes:

  • 070.2, 070.3, V02.61

Denominator Calculation:

  1. The number of patients who are age >=1 year and <2 years and have at least one face-to-face encounter during the reporting period.

Population Criteria #12: DTaP, IPV, MMR, VZV, Hepatitis B, Pneumococcal vaccines

Numerator Calculation:

1.  DTaP: The number of patients in the denominator that have >= 4 counts of DTaP vaccine recorded in the SOAPnote Plan field; occurring >=42 days and <2 years after the patients birth date.  The DTaP vaccine can be recorded in the SOAPnote Plan field by using the following codes:

  • c90721oi: DTAP-HIB VACCINE, IM (CVX code 50)
  • c90723oi: DTAP-HEP B-IPV, IM (CVX code 110)
  • c90696oi: DTAP-IPV VACC, 4-6 YR, IM (CVX code 130)
  • c90698oi: DTAP-HIB-IP VACCINE, IM (CVX code 120)
  • c90700oi: DTAP VACCINE, <7 YRS, IM or DTAP 5 PERTUSS ANT VACC, <7 YRS, IM (CVX code 20)

2.  IPV: The number of patients in the denominator that have >=3 counts of IPV vaccine recorded in the SOAPnote Plan field; occurring >=42 days and <2 years after the patients birth date.  The IPV vaccine can be recorded in the SOAPnote Plan field by using the following codes:

  • c90696oi: DTAP-IPV VACC, 4-6 YR, IM (CVX code 130)
  • c90698oi: DTAP-HIB-IP VACCINE, IM (CVX code 120)
  • c90713oi: POLIOVIRUS, IPV, SC/IM (CVX code 10)
  • c90723oi: DTAP-HEP B-IPV, IM (CVX code 110)

3.  MMR: The number of patients in the denominator that have >=1 counts of MMR vaccine recorded in the SOAPnote Plan field; occurring <2 years after the patients birth date.  The MMR vaccine can be recorded in the SOAPnote Plan field by using the following codes:

  • c90707oi: MMR VACCINE, SC (CVX code 03)
  • c90710oi: MMRV VACC, SC (CVX code 94)

4. VZV: The number of patients in the denominator that have >=1 counts of VZV vaccine recorded in the SOAPnote Plan field; occurring <2 years after the patients birth date.  The VZV vaccine can be recorded in the SOAPnote Plan field by using the following codes:

  • c90710oi: MMRV VACC, SC (CVX code 94)
  • c90716oi: CHICKEN POX VACCINE, SC (CVX code 21)

5. Hepatitis B: The number of patients in the denominator that have >=3 counts of Hepatitis B vaccine recorded in the SOAPnote Plan field; occurring <2 years after the patients birth date.  The Hepatitis B vaccine can be recorded in the SOAPnote Plan field by using the following codes:

  • c90636oi: HEP A/HEP B VACCINE, ADULT, IM (CVX code 104)
  • c90723oi: DTAP-HEP B-IPV, IM (CVX code 110)
  • c90747oi: HEPB VACC, ILL PAT 4-D IM (CVX code 44)
  • c90740oi: HEPB VACC, ILL PAT 3-D IM (CVX code 44)
  • c90746oi: HEP B VACCINE, ADULT, IM (CVX code 43)
  • c90743oi: HEP B VACC, ADOL, 2 DOSE, IM (CVX code 43)
  • c90748oi: HEP B/HIB VACCINE, IM (CVX code 51)

OR

Diagnosis resolved: Hepatitis B diagnosis in the Summary Inactive Problems field using one of the following ICD9 codes:

  • 070.2, 070.3, V02.61

6. Pneumococcal: The number of patients in the denominator that have >=4 counts of Pneumococcal vaccine recorded in the SOAPnote Plan field; occurring >=42 days and <2 years after the patients birth date.  The Pneumococcal vaccine can be recorded in the SOAPnote Plan field by using the following codes:

  • c90669oi: PNEUMOCOCCAL VACC, PED <5 (CVX code 100)
  • c90670oi: PNEUMOCOCCAL VACC, 13 VAL IM (CVX code 133)

Denominator Calculation:

  1. The number of patients who are age >=1 year and <2 years and have at least one face-to-face encounter during the reporting period.

CQM Export

CQM Export

This measure exports 12 different numerators and denominators.  The immunization related to each numerator measure is listed below:

Numerator - Measure

Numerator 1- DTAP

Numerator 2 - IPV

Numerator 3 - MMR

Numerator 4 - HIB

Numerator 5 - HEPB

Numerator 6 - VZV

Numerator 7 - Pneumococcal

Numerator 8 - HEPA

Numerator 9 - Rotavirus

Numerator 10 - Influenza

Numerator 11 - DTaP, IPV, MMR, VZV, Hepatitis B

Numerator 12 - DTaP, IPV, MMR, VZV, Hepatitis B, Pneumococcal

Report Clinical Quality Measures to CMS/States

All of the items listed in the above steps need to be documented as structured data (as detailed above) in order to allow the user to capture the numerator, denominator and percentage for this quality measure.  

For information on how to export the numerator, denominator and percentage for each Clinical Quality Measure, click here.

For more information on reporting clinical quality measures, click here.