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  1. eCQM Issue Tracker
  2. CQM-7322

CMS-117 Childhood Immunizations: Clarification on intent of measure denominator

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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    • Amanda Fredrickson
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      Thank you for your inquiry about CMS117v12 (2024 Performance Period). According to the measure steward, the National Committee for Quality Assurance (NCQA), the measure's logic does not require that vaccines or diagnoses be linked to the clinician who provided the initial population qualifying encounter. Therefore, if a patient meets the initial population criteria upon visiting your facility, they will be included in the measure. We are exploring how to better attribute patients to providers responsible for vaccinations and will consider updates in a future annual update cycle.
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      Thank you for your inquiry about CMS117v12 (2024 Performance Period). According to the measure steward, the National Committee for Quality Assurance (NCQA), the measure's logic does not require that vaccines or diagnoses be linked to the clinician who provided the initial population qualifying encounter. Therefore, if a patient meets the initial population criteria upon visiting your facility, they will be included in the measure. We are exploring how to better attribute patients to providers responsible for vaccinations and will consider updates in a future annual update cycle.
    • CMS0117v12

      The initial population for this measure is defined as 'Children who turn 2 years of age during the measurement period and have a visit during the measurement period'.  

      Our organization is observing patients who are seen for the first time at one of our locations after the patient has turned 24 months.  Due to the fact that the patient turns 2 years of age during the measurement period (MP) and because they have an eligible visit during the measurement period the patients are included in the measure denominator.

      Scenario:

      Patient's date of birth = 3/24/2022 (turns 2 years of age during the current MP)

      Patient seen for the first time at our facility on 8/27/2024 (patient now age 29 months) with an eligible visit.

      Is the intent of the measure to include patients that the organization was not providing care for (and thus unable to address immunization needs for) prior to 24 months of age?

       

            AIR EC eCQM Team AIR EC eCQM Team
            Shari Black Shari Black
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