Immunization (IMM)
Paper Tool for Discharge Measure Influenza Immunization (IMM-2)
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
This paper abstraction tool is provided as an optional, informal mechanism to aid
psychiatric facilities and hospital psychiatric units in the collection of the measures
for the CMS Inpatient Psychiatric Facility Quality Reporting Program. The tool is
designed to collect patient specific data; however, once abstracted the data will
need to be compiled and reported to CMS in aggregate. It should be noted that
skip logic is not contained within the paper abstraction tool. If there are any
questions or concerns regarding use of this paper abstraction tool, please contact
the IPFQR Program Support Contractor at IPFQualityReporting@hcqis.org.
Birthdate: ________/________/_________________
UTD is not an allowable entry
Patient Identifier: _________________________________
Admission Date: ________/________/_________________
UTD is not an allowable entry
Discharge Date: ________/________/_________________
UTD is not an allowable entry
Individual Medical Record Data Collection Tool
During review of the record, the abstractor will be prompted to enter a 0 or a 1 for both
the numerator and denominator for the measure below.
Patient Level - IMM-2
_________ Numerator
_________ Denominator
The information from each medical record will be used to determine the numerator and
denominator which will be aggregated for submission to QualityNet.
CMS Abstraction Paper Tool – IMM-2
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 1 of 4
Immunization (IMM)
Paper Tool for Discharge Measure Influenza Immunization (IMM-2)
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
IMM-2
1. What is the patient’s age? Patient Age (in years) is calculated by Admission
Date minus Birthdate. ________________________________
a. If Patient Age is less than 6 months old, then the case will be excluded
(Measure Category Assignment of “B”). Stop abstracting. The case will
not be included in the numerator or denominator for IMM-2. Add 0 to
the numerator and denominator for IMM-2.
b. If Patient Age is 6 months or greater, then continue abstracting and
proceed to ICD-9-CM Principal and ICD-9-CM Other Procedure Codes.
2. What was the ICD-9-CM code selected as the principal procedure for this
record? (ICD-9-CM Principal Procedure Code) __________________
What was the ICD-9-CM code(s) selected as the other procedure for this
record? (ICD-9-CM Other Procedure Codes) __________________
a. If at least one code above is on Table 12.10, then the case will be
excluded (Measure Category Assignment of “B”). Stop abstracting.
The case will not be included in the numerator or denominator for IMM2. Add 0 to the numerator and denominator for IMM-2.
b. If none of the codes above are on Table 12.10, then continue
abstracting and proceed to Discharge Disposition.
3. What was the patient’s discharge disposition on the day of discharge?
(Discharge Disposition)
_____ 1 Home
_____ 2 Hospice – Home
_____ 3 Hospice – Health Care Facility
_____ 4 Acute Care Facility
_____ 5 Other Health Care Facility
_____ 6 Expired
_____ 7 Left Against Medical Advice (AMA)
_____ 8 Not Documented or Unable to Determine (UTD)
a. If Discharge Disposition Status equals 4, 6, or 7, then the case will be
excluded (Measure Category Assignment of “B”). Stop abstracting. The
case will not be included in the numerator or denominator for IMM-2.
Add 0 to the numerator and denominator for IMM-2.
b. If Discharge Disposition Status equals 1, 2, 3, 5, or 8, then continue
abstracting and proceed to Discharge Date.
CMS Abstraction Paper Tool – IMM-2
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 2 of 4
Immunization (IMM)
Paper Tool for Discharge Measure Influenza Immunization (IMM-2)
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
4. Discharge Date: ________/________/________ All dates are in MM-DD-YYYY
(UTD is not allowable entry)
a. If the discharge date is 10-01-yyyy through 03-31-yyyy, then continue
abstracting and proceed to ICD-9-CM Principal and ICD-9-CM Other
Procedure Codes.
b. If the discharge date is 04-01-yyyy through 09-30-yyyy, then the case
will be excluded (Measure Category Assignment of “B”). Stop
abstracting. The case will not be included in the numerator or
denominator for IMM-2. Add 0 to the numerator and denominator for
IMM-2.
5. Refer to the ICD-9-CM Principal or Other Procedure Codes listed in #2. (ICD-9CM Principal or ICD-9-CM Other Procedure Codes)
a. If none of the codes above are on Table 12.9, continue and proceed to
Influenza Vaccination Status.
b. If at least one code above is on Table 12.9, the case will be included
(Measure Category Assignment of “E”). Stop abstracting. Add 1 to
BOTH the numerator and denominator for IMM-2.
6. What is the patient’s influenza vaccination status? (Influenza Vaccination
Status)
_____ 1 Influenza vaccine was given during this hospitalization.
_____ 2 Influenza vaccine was received prior to admission during the current flu
season, not during this hospitalization.
_____ 3 Documentation of patient's or caregiver’s refusal of influenza vaccine.
_____ 4 There was documentation of an allergy/sensitivity to influenza vaccine,
anaphylactic latex allergy or anaphylactic allergy to eggs OR is not likely
to be effective because of bone marrow transplant within the past 6
months OR history of Guillian-Barré syndrome within 6 weeks after a
previous influenza vaccination.
_____ 5 None of the above/Not documented/Unable to determine from medical
record documentation.
_____ 6 Only select this allowable value if there is documentation the vaccine has
been ordered but has not yet been received by the hospital due to
problems with vaccine production or distribution AND allowable values 1-5
are not selected.
a. If Influenza Vaccination Status equals 1, 2, 3, or 4, the case will be
included (Measure Category Assignment “E”). Stop abstracting. Add
1 to BOTH the numerator and denominator for IMM-2.
CMS Abstraction Paper Tool – IMM-2
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 3 of 4
Immunization (IMM)
Paper Tool for Discharge Measure Influenza Immunization (IMM-2)
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
b. If the Influenza Vaccination Status equals 5, the case will be included
(Measure Category Assignment of “D”). Stop abstracting. Add 1 to the
denominator for IMM-2. Add 0 to the numerator for IMM-2.
c. If Influenza Vaccination Status equals 6, the case will be excluded
(Measure Category Assignment of “B”). Stop abstracting. The case will
not be included in the numerator or denominator for IMM-2. Add 0 to
the numerator and denominator for IMM-2.
This material was prepared by the Inpatient Value, Incentives, and Quality Reporting Outreach and Education
Support Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S.
Department of Health and Human Services. HHSM-500-2013-13007I, FL-IQR-Ch8-02052015-05
CMS Abstraction Paper Tool – IMM-2
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
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