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Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

CMS Measure ID
CMS138v8
Version
8
NQF Number
0028e
Measure Description

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

Three rates are reported:

a. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months

b. Percentage of patients aged 18 years and older who were identified as a tobacco user who received tobacco cessation intervention

c. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

Initial Population

All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period

Denominator Statement

Population 1:

Equals Initial Population

Population 2:

Equals Initial Population who were screened for tobacco use and identified as a tobacco user

Population 3:

Equals Initial Population

Denominator Exclusions

None

Numerator Statement

Population 1:

Patients who were screened for tobacco use at least once within 24 months

 

Population 2:

Patients who received tobacco cessation intervention

Population 3:

Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

Numerator Exclusions

Not Applicable

Denominator Exceptions

Population 1:

Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reason)

 

Population 2:

Documentation of medical reason(s) for not providing tobacco cessation intervention (e.g., limited life expectancy, other medical reason)

Population 3:

Documentation of medical reason(s) for not screening for tobacco use OR for not providing tobacco cessation intervention for patients identified as tobacco users (e.g., limited life expectancy, other medical reason)

Previous Version
Measure Scoring
Measure Type
Improvement Notation

Higher score indicates better quality

Guidance

If a patient uses any type of tobacco (i.e., smokes or uses smokeless tobacco), the expectation is that they should receive tobacco cessation intervention: either counseling and/or pharmacotherapy.

In order to promote a team-based approach to patient care, the tobacco cessation intervention can be performed by another healthcare provider; therefore, the tobacco use screening and tobacco cessation intervention do not need to be performed by the same provider or clinician.

To satisfy the intent of this measure, a patient must have at least one tobacco use screening during the 24-month period. If a patient has multiple tobacco use screenings during the 24-month period, only the most recent screening, which has a documented status of tobacco user or tobacco non-user, will be used to satisfy the measure requirements.

If tobacco use status of a patient is unknown, the patient does not meet the screening component required to be counted in the numerator and should be considered a measure failure. Instances where tobacco use status of "unknown" is recorded include: 1) the patient was not screened; or 2) the patient was screened and the patient (or caregiver) was unable to provide a definitive answer. If the patient does not meet the screening component of the numerator but has an allowable medical exception, then the patient should be removed from the denominator of the measure and reported as a valid exception.

The medical reason exception may be applied to either the screening data element OR to any of the applicable tobacco cessation intervention data elements (counseling and/or pharmacotherapy) included in the measure.

If a patient has a diagnosis of limited life expectancy, that patient has a valid denominator exception for not being screened for tobacco use or for not receiving tobacco use cessation intervention (counseling and/or pharmacotherapy) if identified as a tobacco user.

As noted above in a recommendation statement from the USPSTF, the current evidence is insufficient to recommend electronic nicotine delivery systems (ENDS) including electronic cigarettes for tobacco cessation. Additionally, ENDS are not currently classified as tobacco in the recent evidence review to support the update of the USPSTF recommendation given that the devices do not burn or use tobacco leaves. In light of the current lack of evidence, the measure does not currently capture e-cigarette usage as either tobacco use or a cessation aid.

The requirement of two or more visits is to establish that the eligible professional or eligible clinician has an existing relationship with the patient for certain types of encounters.

This measure contains three reporting rates which aim to identify patients who were screened for tobacco use (rate/population 1), patients who were identified as tobacco users and who received tobacco cessation intervention (rate/population 2), and a comprehensive look at the overall performance on tobacco screening and cessation intervention (rate/population 3). By separating this measure into various reporting rates, the eligible professional or eligible clinician will be able to better ascertain where gaps in performance exist, and identify opportunities for improvement. The overall rate (rate/population 3) can be utilized to compare performance to published versions of this measure prior to the 2018 performance year, when the measure had a single performance rate. For accountability reporting in the CMS MIPS program, the rate for population 2 is used for performance.

The denominator of population criteria 2 is a subset of the resulting numerator for population criteria 1, as population criteria 2 is limited to assessing if patients identified as tobacco users received an appropriate tobacco cessation intervention. For all patients, population criteria 1 and 3 are applicable, but population criteria 2 will only be applicable for those patients who are identified as tobacco users. Therefore, data for every patient that meets the initial population criteria will only be submitted for population 1 and 3, whereas data submitted for population 2 will be for a subset of patients who meet the initial population criteria, as the denominator has been further limited to those who were identified as tobacco users.

Quality ID
226

Specifications

Attachment Size
CMS138v8.html 82.08 KB
CMS138v8.zip 71.71 KB
CMS138v8-TRN.xlsx 22.06 KB

Release Notes

 

Header

  • Updated eCQM version number.

    Measure Section: eCQM Version number

    Source of Change: Measure Lead

  • Added 'e' to NQF number.

    Measure Section: NQF Number

    Source of Change: Standards Update

  • Updated description statement to clarify the intent of Population Criteria 2.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated disclaimer.

    Measure Section: Disclaimer

    Source of Change: Measure Lead

  • Updated references to align with American Psychological Association (APA) style.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated definition statement for 'Tobacco Cessation Intervention' to include information related to frequency.

    Measure Section: Definition

    Source of Change: Measure Lead

  • Updated guidance statement last paragraph to further clarify the difference between the various populations.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated guidance statement paragraph nine to specifically indicate which population is used for accountability reporting in CMS programs.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated guidance statement with addition of wording to clarify that a patient must have at least one tobacco use screening during the specified timeframe.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated parenthetical citations to align with American Psychological Association (APA) style.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

 

Logic

  • Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with CQL Style Guide.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MAT) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

 

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set Occupational Therapy Evaluation (2.16.840.1.113883.3.526.3.1011): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1774) including 2 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Psychoanalysis (2.16.840.1.113883.3.526.3.1141): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1778) including 2 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Tobacco User (2.16.840.1.113883.3.526.3.1170): Added 10 SNOMED CT codes (110483000, 228499007, 43381005, 449867007, 56578002, 56771006, 449869005, 450811000124104, 450821000124107, 713914004).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Tobacco Non-User (2.16.840.1.113883.3.526.3.1189): Added 14 SNOMED CT codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Annual Wellness Visit (2.16.840.1.113883.3.526.3.1240): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1772) including 2 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Ophthalmological Services (2.16.840.1.113883.3.526.3.1285): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1771) including 4 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Psych Visit - Diagnostic Evaluation (2.16.840.1.113883.3.526.3.1492): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1776) including 5 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Psych Visit - Psychotherapy (2.16.840.1.113883.3.526.3.1496): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1777) including 13 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Speech and Hearing Evaluation (2.16.840.1.113883.3.526.3.1530): Added SNOMED CT extensional value set (2.16.840.1.113883.3.526.2.1773) including 4 codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Tobacco Use Cessation Counseling (2.16.840.1.113883.3.526.3.509): Added 1 SNOMED CT code (713700008).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Standardized purpose statement language in value sets across eCQMs. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jul 22, 2019