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  2. CQM-6673

CMS 117 - Rotavirus - 2 or 3 dose Narrative vs Logic

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    • Resolution: Answered
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    • Crystal Harvey
    • Medisolv
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      Thank you for your inquiry about CMS117v11: Childhood Immunization Status. The logic for the "Has Appropriate Number of Rotavirus Immunizations" definition will identify all rotavirus doses occurring on different days. In the logic, the "HasThreeDose" will be set to true if a patient has a rotavirus 3 dose immunization or procedure. The logic further evaluates if the patient has an appropriate number of doses of either of the combinations mentioned below. If a patient does not have the appropriate number of doses for the three-dose rotavirus, the logic will then evaluate to see if the patient had two doses of the two-dose rotavirus vaccine.

      CMS117v11:
      • At least two doses of the two-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.
      • At least three doses of the three-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.
      • 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. Do not count a vaccination administered prior to 42 days after birth.
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      Thank you for your inquiry about CMS117v11: Childhood Immunization Status. The logic for the "Has Appropriate Number of Rotavirus Immunizations" definition will identify all rotavirus doses occurring on different days. In the logic, the "HasThreeDose" will be set to true if a patient has a rotavirus 3 dose immunization or procedure. The logic further evaluates if the patient has an appropriate number of doses of either of the combinations mentioned below. If a patient does not have the appropriate number of doses for the three-dose rotavirus, the logic will then evaluate to see if the patient had two doses of the two-dose rotavirus vaccine. CMS117v11: • At least two doses of the two-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth. • At least three doses of the three-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth. • 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. Do not count a vaccination administered prior to 42 days after birth.
    • CMS0117v11
    • Rotavirus 2 or 3 dose logic seems to contradict the narrative description. This may negatively impact performance scores.

      In the measure description, this is the criteria for the Rotavirus:

      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. Do not count a vaccination administered prior to 42 days after birth.
      •    At least three doses of the three-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.
      •    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. Do not count a vaccination administered prior to 42 days after birth.
      •    Anaphylaxis due to the rotavirus vaccine on or before the child’s second birthday.

       

      For the third option of at least one dose of the two-dose and at least two doses of the three-dose, the narrative appears to contradict the logic. In the logic it appears to check to see if the patient has had ANY rotavirus 3 dose immunization or procedure. If the patient does, this "HasThreeDose" gets set to True. It will not get set to False anywhere further down, so the check for >/= 2 records at the bottom is never evaluated. The presence of the three dose code basically forces the measure to require 3 rotavirus vaccine records. 

       

      Is this the correct interpretation? Please advise.

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            edave Mathematica EC eCQM Team
            harveycr Crystal Harvey
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