CHILDHOOD IMMUNIZATIONS (CIS)

APPLICATIONS HEDIS® (Hybrid) NCQA Accreditation EPSDT*

OBJECTIVE Purpose of Measure:

To identify children due for an immunization

ELIGIBLE POPULATION Which members are included?

Children who turn two (2) years of age as of December 31st of the measurement year. Members in hospice are excluded from the eligible population.

STANDARD OF CARE What immunizations should be administered?

By their second (2nd) birthday, children should receive all of the following:

• 4 – diphtheria, tetanus, and acellular pertussis (DTaP)

• 3 – polio (IVP) • 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)

Note: The member must have all of the recommended doses of each vaccine prior to their second birthday in order to be compliant with HEDIS®. Rates are calculated on individual vaccines and in combinations as outlined in NCQA’s HEDIS® Technical Specifications.

NCQA ACCEPTED CODES Please see code table. DOCUMENTATION REQUIREMENTS What documentation should be submitted?

For each immunization given: • A note indicating the name of the

immunization and date given, or • A certificate of immunization prepared

by an authorized health care provider or agency that includes the type of

immunization and date administered. State immunization certificates should be signed and dated.

• For Hepatitis B, notations that the first dose was administered “at birth” or “in the hospital” are acceptable.

• For Rotavirus, the documentation should indicate whether the two- or three-dose schedule was administered. If the documentation does not clearly indicate if the two-or three-dose vaccine was given, it will be assumed the three-dose was used.

• Flumist is not acceptable for either dose of the required influenza vaccines.

• Documentation of parental refusal of vaccines(s) is not compliant under HEDIS specifications.

For each immunization not given:

• Documentation of a contraindication to the vaccine or its components, (such as anaphylactic reaction).

• DTaP: diagnosis of encephalopathy • IVP: anaphylactic reaction to

streptomycin, polymyxin B, or neomycin • MMR, VZV, and influenza:

immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma, leukemia, or anaphylactic reaction to neomycin

• Hepatitis B: anaphylactic reaction to common baker’s yeast

• A documented history of the illness or a seropositive test result. Note must indicate date of the event, which must have occurred prior to the member’s second (2nd) birthday.

REFERENCES For more information, please refer to Passport Health Plan’s Preventive Health Clinical Practice Guideline including current immunization schedules, KY EPSDT Manual, and the AAP Bright Futures Provider Toolkit.

• The criteria above are based on standards established under NCQA’s

HEDIS 2018 Technical Specifications. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

*The Early and Periodic Screening Diagnosis and Treatment (EPSDT) program is designed to provide a comprehensive preventive health care package to members from birth to age 21. For billing and or other questions/concerns please contact your Provider Network Manager or Provider Services at (800)-578-0775.

CHILDHOOD IMMUNIZATION STATUS

Meet Screening Criteria DTaP Vaccine Code System Code CPT 90698 CPT 90700 CPT 90721 CPT 90723 CVX 20 diphtheria, tetanus toxoids and acellular pertussis vaccine CVX 50 DTaP-Haemophilus influenzae type b conjugate vaccine CVX 106 diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens CVX 107 diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified formulation

CVX 110 DTaP-hepatitis B and poliovirus vaccine CVX 120 diphtheria, tetanus toxoids and acellular pertussis vaccine, Haemophilus influenzae

type b conjugate, and poliovirus vaccine, inactivated (DTaP-Hib-IPV)

Inactivated Polio Vaccine (IPV) Code System Code CPT 90698

CPT 90713

CPT 90723 CVX 10 poliovirus vaccine, inactivated CVX 89 poliovirus vaccine, unspecified formulation

CVX 110 DTaP-hepatitis B and poliovirus vaccine CVX 120 diphtheria, tetanus toxoids and acellular pertussis vaccine, Haemophilus influenzae

type b conjugate, and poliovirus vaccine, inactivated (DTaP-Hib-IPV)

MMR Vaccine Code System Code Measles, Mumps and Rubella Vaccine CPT 90707 CPT 90710 CVX 03 measles, mumps and rubella virus vaccine

CVX 94 measles, mumps, rubella, and varicella virus vaccine

Measles/Rubella Vaccine CPT 90708 CVX 04 measles and rubella virus vaccine

Measles Vaccine CPT 90705 CVX 05 measles virus vaccine Mumps Vaccine CPT 90704

CVX 07 mumps virus vaccine Rubella Vaccine CPT 90706 CVX 06 rubella virus vaccine

Measles ICD10CM B05.0 [B05.0] Measles complicated by encephalitis ICD10CM B05.1 [B05.1] Measles complicated by meningitis ICD10CM B05.2 [B05.2] Measles complicated by pneumonia

ICD10CM B05.3 [B05.3] Measles complicated by otitis media ICD10CM B05.4 [B05.4] Measles with intestinal complications ICD10CM B05.81 [B05.81] Measles keratitis and keratoconjunctivitis ICD10CM B05.89 [B05.89] Other measles complications ICD10CM B05.9 [B05.9] Measles without complication ICD9CM 055.0 Postmeasles encephalitis ICD9CM 055.1 Postmeasles pneumonia ICD9CM 055.2 Postmeasles otitis media ICD9CM 055.71 Measles keratitis ICD9CM 055.79 Measles complication NEC ICD9CM 055.8 Measles complication NOS ICD9CM 055.9 Measles uncomplicated Mumps ICD10CM B26.0 [B26.0] Mumps orchitis ICD10CM B26.1 [B26.1] Mumps meningitis ICD10CM B26.2 [B26.2] Mumps encephalitis ICD10CM B26.3 [B26.3] Mumps pancreatitis ICD10CM B26.81 [B26.81] Mumps hepatitis ICD10CM B26.82 [B26.82] Mumps myocarditis ICD10CM B26.83 [B26.83] Mumps nephritis ICD10CM B26.84 [B26.84] Mumps polyneuropathy ICD10CM B26.85 [B26.85] Mumps arthritis ICD10CM B26.89 [B26.89] Other mumps complications ICD10CM B26.9 [B26.9] Mumps without complication ICD9CM 072.0 Mumps orchitis ICD9CM 072.1 Mumps meningitis ICD9CM 072.2 Mumps encephalitis ICD9CM 072.3 Mumps pancreatitis ICD9CM 072.71 Mumps hepatitis ICD9CM 072.72 Mumps polyneuropathy ICD9CM 072.79 Mumps complication NEC ICD9CM 072.8 Mumps complication NOS ICD9CM 072.9 Mumps uncomplicated Rubella ICD10CM B06.00 [B06.00] Rubella with neurological complication, unspecified

ICD10CM B06.01 [B06.01] Rubella encephalitis ICD10CM B06.02 [B06.02] Rubella meningitis ICD10CM B06.09 [B06.09] Other neurological complications of rubella ICD10CM B06.81 [B06.81] Rubella pneumonia ICD10CM B06.82 [B06.82] Rubella arthritis ICD10CM B06.89 [B06.89] Other rubella complications ICD10CM B06.9 [B06.9] Rubella without complication ICD9CM 056.00 Rubella nerve compl NOS ICD9CM 056.01 Rubella encephalitis ICD9CM 056.09 Rubella nerve compl NEC ICD9CM 056.71 Arthritis due to rubella ICD9CM 056.79 Rubella complication NEC ICD9CM 056.8 Rubella complication NOS ICD9CM 056.9 Rubella uncomplicated

HiB Vaccine Code System Code CPT 90644 CPT 90645 CPT 90646 CPT 90647 CPT 90648 CPT 90698 CPT 90721 CPT 90748 CVX 17 Haemophilus influenzae type b vaccine, conjugate unspecified formulation CVX 46 Haemophilus influenzae type b vaccine, PRP-D conjugate CVX 47 Haemophilus influenzae type b vaccine, HbOC conjugate CVX 48 Haemophilus influenzae type b vaccine, PRP-T conjugate CVX 49 Haemophilus influenzae type b vaccine, PRP-OMP conjugate CVX 50 DTaP-Haemophilus influenzae type b conjugate vaccine CVX 51 Haemophilus influenzae type b conjugate and Hepatitis B vaccine CVX 120 diphtheria, tetanus toxoids and acellular pertussis vaccine, Haemophilus influenzae

type b conjugate, and poliovirus vaccine, inactivated (DTaP-Hib-IPV) CVX 148 Meningococcal Groups C and Y and Haemophilus b Tetanus Toxoid Conjugate

Vaccine Hepatitis B Vaccine Code System Code Definition CPT 90723 CPT 90740 CPT 90744 CPT 90747 CPT 90748 CVX 08 hepatitis B vaccine, pediatric or pediatric/adolescent dosage CVX 44 hepatitis B vaccine, dialysis patient dosage

CVX 45 hepatitis B vaccine, unspecified formulation

CVX 51 Haemophilus influenzae type b conjugate and Hepatitis B vaccine CVX 110 DTaP-hepatitis B and poliovirus vaccine HCPCS G0010 Administration of hepatitis b vaccine (G0010) Varicella Zoster (VZV) Vaccine Code System Code Definition CPT 90710 CPT 90716 CVX 21 varicella virus vaccine CVX 94 measles, mumps, rubella, and varicella virus vaccine Pneumococcal Conjugate Vaccine Code System Code Definition CPT 90669 CPT 90670 CVX 100 pneumococcal conjugate vaccine, 7 valent CVX 133 pneumococcal conjugate vaccine, 13 valent CVX 152 Pneumococcal Conjugate, unspecified formulation HCPCS G0009 Administration of pneumococcal vaccine (G0009) Hepatitis A Vaccine Code System Code Definition CPT 90633 CVX 31 hepatitis A vaccine, pediatric dosage, unspecified formulation CVX 83 hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule CVX 85 hepatitis A vaccine, unspecified formulation Rotavirus Vaccine Code System Code Definition CPT 90681 CVX 119 rotavirus, live, monovalent vaccine CPT 90680 CVX 116 rotavirus, live, pentavalent vaccine CVX 122 rotavirus vaccine, unspecified formulation

Influenza Vaccine Code System Code Definition CPT 90655 CPT 90657 CPT 90661 CPT 90662 CPT 90673 CPT 90685 CPT 90687 CPT 90688 CVX 88 influenza virus vaccine, unspecified formulation CVX 135 influenza, high dose seasonal, preservative-free

CVX 140 Influenza, seasonal, injectable, preservative free CVX 141 Influenza, seasonal, injectable CVX 150 Influenza, injectable, quadrivalent, preservative free CVX 153 Influenza, injectable, Madin Darby Canine Kidney, preservative free CVX 155 Seasonal, trivalent, recombinant, injectable influenza vaccine, preservative free CVX 158 influenza, injectable, quadrivalent, contains preservative

CVX 161 Influenza, injectable,quadrivalent, preservative free, pediatric HCPCS G0008 Administration of influenza virus vaccine (G0008)

Exclusions Any Particular Vaccine Anaphylactic reaction to the vaccine or its components DTaP Encephalopathy with a vaccine adverse-effect code set MMR, VZV and Influenza Immunodeficiency HIV Lymphoreticular cancer, multiple myeloma or leukemia Anaphylactic reaction to neomycin Rotavirus Severe combined immunodeficiency History of intussusception IPV Anaphylactic reaction to streptomycin, polymyxin B or neomycin Hepatitis B Anaphylactic reaction to common baker’s yeast