PT ‐ 2020 Measure Value Set_Immunizations for Adolescents

Numerator Value Set Name Code Definition Code System Meningococcal 108 meningococcal ACWY , unspecified formulation CVX meningococcal polysaccharide (groups A, C, Y and W‐135) conjugate Meningococcal Immunization 114 CVX vaccine (MCV4P) meningococcal oligosaccharide (groups A, C, Y and W‐135) diphtheria toxoid conjugate Meningococcal Immunization 136 CVX vaccine (MCV4O) Meningococcal Immunization 147 Meningococcal, MCV4, unspecified conjugate formulation(groups A, C, Y and W‐135) CVX Meningococcal Immunization 167 of unknown formulation and unknown serogroups CVX Meningococcal Vaccine Procedure 90734 CPT Meningococcal Vaccine Procedure 390892002 Meningitis ACW & Y (procedure) SNOMED CT US Edition Tdap Immunization 115 tetanus toxoid, reduced diphtheria toxoid, and acellular , adsorbed CVX Tdap Vaccine Procedure 90715 CPT Tdap Vaccine Procedure 428251000124104 Tetanus, diphtheria and acellular pertussis vaccination (procedure) SNOMED CT US Edition HPV Immunization 62 human papilloma virus vaccine, quadrivalent CVX HPV Immunization 118 human papilloma virus vaccine, bivalent CVX HPV Immunization 137 HPV, unspecified formulation CVX HPV Immunization 165 Human Papillomavirus 9‐valent vaccine CVX HPV Vaccine Procedure 90649 CPT HPV Vaccine Procedure 90650 CPT HPV Vaccine Procedure 90651 CPT HPV Vaccine Procedure 428570002 Vaccination for human papillomavirus (procedure) SNOMED CT US Edition HPV Vaccine Procedure 428741008 Vaccination with first dose of human papillomavirus (procedure) SNOMED CT US Edition HPV Vaccine Procedure 428931000 Vaccination with third dose of human papillomavirus (procedure) SNOMED CT US Edition HPV Vaccine Procedure 429396009 Vaccination with second dose of human papillomavirus (procedure) SNOMED CT US Edition HPV Vaccine Procedure 734152003 Administration of human papilloma virus type 6, 11, 16, and 18 vaccine (procedure) SNOMED CT US Edition

HPV Vaccine Procedure 734154002 Administration of human papilloma virus type 6, 11, 16, and 18 vaccine done (situation) SNOMED CT US Edition HPV Vaccine Procedure 99501000119107 Human papilloma virus vaccination given (situation) SNOMED CT US Edition

Page 1 of 4 November 2019 PT ‐ 2020 Measure Value Set_Immunizations for Adolescents

Exclusions Value Set Name Code Definition Code System

Anaphylactic Reaction Due To Serum 213320003 Anaphylactic shock caused by serum (disorder) SNOMED CT US Edition Anaphylactic Reaction Due To T80.52XA [T80.52XA] Anaphylactic reaction due to vaccination, initial encounter ICD10CM Vaccination Anaphylactic Reaction Due To T80.52XD [T80.52XD] Anaphylactic reaction due to vaccination, subsequent encounter ICD10CM Vaccination Anaphylactic Reaction Due To T80.52XS [T80.52XS] Anaphylactic reaction due to vaccination, sequela ICD10CM Vaccination

Anaphylactic Reaction Due To 428241000124 Anaphylaxis due to human papillomavirus vaccine (disorder) SNOMED CT US Edition Vaccination 101 Anaphylactic Reaction Due To 428281000124 Anaphylaxis due to diphtheria and (disorder) SNOMED CT US Edition Vaccination 107 Anaphylactic Reaction Due To 428291000124 Anaphylaxis due to tetanus, diphtheria and acellular pertussis vaccine (disorder) SNOMED CT US Edition Vaccination 105 Anaphylactic Reaction Due To 428301000124 Anaphylaxis due to meningococcal vaccine (disorder) SNOMED CT US Edition Vaccination 106 Anaphylactic Reaction Due To 428321000124 Anaphylaxis due to (disorder) SNOMED CT US Edition Vaccination 101 Anaphylactic Reaction Due To 428331000124 Anaphylaxis due to (disorder) SNOMED CT US Edition Vaccination 103 Anaphylactic Reaction Due To 433621000124 Anaphylaxis due to Haemophilus influenzae type b vaccine (disorder) SNOMED CT US Edition Vaccination 101 Encephalopathy Due To Vaccination G04.32 [G04.32] Postimmunization acute necrotizing hemorrhagic encephalopathy ICD10CM

Encephalopathy Due To Vaccination 192704009 Post‐immunization encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192705005 Post‐bacillus Calmette‐Guerin vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192706006 Post typhoid vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192707002 Post paratyphoid vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192708007 Post cholera vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192709004 Post plague vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192710009 Post tetanus vaccination encephalitis (disorder) SNOMED CT US Edition

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Exclusions Value Set Name Code Definition Code System Encephalopathy Due To Vaccination 192711008 Post diphtheria vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192712001 Post pertussis vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192713006 Post smallpox vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192714000 Post rabies vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192715004 Post typhus vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192716003 Post yellow fever vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192717007 Post measles vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192718002 Post polio vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192719005 Post mumps vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192720004 Post rubella vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192721000 Post influenza vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192722007 Post hepatitis A vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192723002 Post hepatitis B vaccination encephalitis (disorder) SNOMED CT US Edition

Encephalopathy Due To Vaccination 192724008 Post mixed vaccination encephalitis (disorder) SNOMED CT US Edition [T50.A15A] Adverse effect of pertussis vaccine, including combinations with a pertussis Vaccine Causing Adverse Effect T50.A15A ICD10CM component, initial encounter [T50.A15D] Adverse effect of pertussis vaccine, including combinations with a pertussis Vaccine Causing Adverse Effect T50.A15D ICD10CM component, subsequent encounter [T50.A15S] Adverse effect of pertussis vaccine, including combinations with a pertussis Vaccine Causing Adverse Effect T50.A15S ICD10CM component, sequela

Vaccine Causing Adverse Effect 219084006 Adverse reaction caused by tetanus vaccine (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 219085007 Adverse reaction caused by diphtheria vaccine (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 219096004 Adverse reaction caused by (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 287180004 Reaction to pertussis vaccine (disorder) SNOMED CT US Edition

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Exclusions Value Set Name Code Definition Code System Vaccine Causing Adverse Effect 288309006 Reaction ‐ mixed vaccine (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 292098007 Allergen extract vaccine adverse reaction (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 293104008 adverse reaction (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 293107001 Diphtheria single antigen vaccine adverse reaction (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 293108006 Diphtheria and tetanus vaccine adverse reaction (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 293109003 Diphtheria, tetanus and pertussis vaccine adverse reaction (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 293110008 Hepatitis B vaccine adverse reaction (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 293112000 Influenza split virion vaccine adverse reaction (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 293113005 Influenza surface antigen vaccine adverse reaction (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 293114004 adverse reaction (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 293115003 Pertussis vaccine adverse reaction (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 293117006 Poliomyelitis vaccine adverse reaction (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 293119009 adverse reaction (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 293125008 Measles/mumps/rubella vaccine adverse reaction (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 293126009 adverse reaction (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 293127000 Haemophilus influenzae Type B vaccine adverse reaction (disorder) SNOMED CT US Edition Vaccine Causing Adverse Effect 420113004 Influenza virus vaccine adverse reaction (disorder) SNOMED CT US Edition 429301000124 Vaccine Causing Adverse Effect Adverse reaction to rotavirus vaccine (disorder) SNOMED CT US Edition 101 429521000124 Vaccine Causing Adverse Effect Adverse reaction to tetanus, diphtheria and acellular pertussis vaccine (disorder) SNOMED CT US Edition 101 451331000124 Vaccine Causing Adverse Effect Adverse reaction caused by varicella virus live vaccine (disorder) SNOMED CT US Edition 106 159201210001 Vaccine Causing Adverse Effect Allergic reaction caused by vaccine (disorder) SNOMED CT US Edition 19103

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