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

Last updated: May 18, 2016

CMS Measure ID: CMS138v3
Version: 3
NQF Number: 0028
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 cessation counseling intervention if identified as a tobacco user

Initial Patient 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:

Equals Initial Patient Population

Denominator Exclusions:

None

Numerator Statement:

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

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

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

Measure Steward: American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI)
Domain: Community, Population and Public Health
Next Version: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Measure Score: Proportion
Score Type: Process
Improvement Notation:

Higher score indicates better quality

Guidance:

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

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.

Exceptions only apply to the screening data element of the measure; once a patient has been screened, there are no allowable exceptions for not providing the intervention.

Specifications

External Resources