eCQM Title | # Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
eCQM Identifier (Measure Authoring Tool) | 138 | eCQM Version Number | 12.0.000
NQF Number | Not Applicable | GUID | e35791df-5b25-41bb-b260-673337bc44a8
Measurement Period | January 1, 20XX through December 31, 20XX
Measure Steward | National Committee for Quality Assurance
Measure Developer | National Committee for Quality Assurance
Measure Developer | American Medical Association (AMA)
Measure Developer | PCPI(R) Foundation (PCPI[R])
Endorsed By | None
Description |
    Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user.

    Three rates are reported:
    a. Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period
    b. Percentage of patients aged 12 years and older who were identified as a tobacco user during the measurement period who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period
    c. Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user
Copyright |
    This Physician Performance Measure (Measure) and related data specifications are owned by the National Committee for Quality Assurance (NCQA). NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in the Measure. The Measure can be reproduced and distributed, without modification, for noncommercial purposes (e.g., use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. The Physician Consortium for Performance Improvement’s (PCPI) and American Medical Association’s (AMA) significant past efforts and contributions to the development and updating of the measure are acknowledged. (C) 2012-2022 National Committee for Quality Assurance. All Rights Reserved.

    Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third-party codes contained in the specifications.

    CPT(R) codes, descriptions and other data are copyright 2022. American Medical Association. All rights reserved. CPT is a trademark of the American Medical Association. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

    LOINC(R) copyright 2004-2022 Regenstrief Institute, Inc.

    This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation.

    ICD-10 copyright 2022 World Health Organization. All Rights Reserved.
Disclaimer |
    The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

    Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Measure Scoring | Proportion
Measure Type | Process
Stratification |
    None
Risk Adjustment |
    None
Rate Aggregation |
    None
Rationale |
    This measure is intended to promote adult tobacco screening and tobacco cessation interventions for those who use tobacco products. There is good evidence that tobacco screening and brief cessation intervention (including counseling and/or pharmacotherapy) is successful in helping tobacco users quit. Tobacco users who are able to stop using tobacco lower their risk for heart disease, lung disease, and stroke.
Clinical Recommendation Statement |
    The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA)-approved pharmacotherapy for cessation to nonpregnant adults who use tobacco (Grade A Recommendation) (U.S. Preventive Services Task Force, 2021).

    The USPSTF recommends that clinicians ask all pregnant persons about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant persons who use tobacco (Grade A Recommendation) (U.S. Preventive Services Task Force, 2021).

    The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant women (Grade I Statement) (U.S. Preventive Services Task Force, 2021).

    The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of electronic cigarettes (e-cigarettes) for tobacco cessation in adults, including pregnant persons. The USPSTF recommends that clinicians direct patients who use tobacco to other tobacco cessation interventions with proven effectiveness and established safety (Grade I Statement) (U.S. Preventive Services Task Force, 2021).

    The USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents (Grade B Statement) (U.S. Preventive Services Task Force, 2020).

    The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care--feasible interventions for the cessation of tobacco use among school-aged children and adolescents (Grade I Statement) (U.S. Preventive Services Task Force, 2020).

    All patients should be asked if they use tobacco and should have their tobacco use status documented on a regular basis. Evidence has shown that clinic screening systems, such as expanding the vital signs to include tobacco use status or the use of other reminder systems such as chart stickers or computer prompts, significantly increase rates of clinician intervention. (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008).

    All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates. (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008).

    Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates. Every tobacco user should be offered at least a minimal intervention, whether or not he or she is referred to an intensive intervention. (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008).

    The combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone. Therefore, whenever feasible and appropriate, both counseling and medication should be provided to patients trying to quit smoking. (Strength of Evidence = A) (U.S. Department of Health and Human Services. Public Health Service, 2008).
Improvement Notation |
    Higher score indicates better quality
Reference |
    Reference Type: CITATION
    Reference Text: 'Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. Rockville (MD): US Department of Health and Human Services; 2008 May. 6, Evidence and Recommendations. Available from: https://www.ncbi.nlm.nih.gov/books/NBK63943/'
Reference |
    Reference Type: CITATION
    Reference Text: 'US Preventive Services Task Force. (2021). Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons. US Preventive Services Task Force Recommendation Statement. JAMA, 325(3), 265-279. doi:10.1001/jama.2020.25019'
Reference |
    Reference Type: CITATION
    Reference Text: 'US Preventive Services Task Force. (2020). Primary Care Interventions for Prevention and Cessation of Tobacco Use in Children and Adolescents. US Preventive Services Task Force Recommendation Statement. JAMA, 2020;323(16):1590-1598. doi:10.1001/jama.2020.4679'
Definition |
    Tobacco Use - Use of any tobacco product

    The 2021 USPSTF recommendation references the US Food and Drug Administration definition of tobacco which includes "any product made or derived from tobacco intended for human consumption (except products that meet the definition of drugs), including, but not limited to, cigarettes, cigars (including cigarillos and little cigars), dissolvables, hookah tobacco, nicotine gels, pipe tobacco, roll-your-own tobacco, smokeless tobacco products (including dip, snuff, snus, and chewing tobacco), vapes, electronic cigarettes (e-cigarettes), hookah pens, and other electronic nicotine delivery systems."

    The 2021 USPSTF recommendation describes smoking as generally referring to "the inhaling and exhaling of smoke produced by combustible tobacco products such as cigarettes, cigars, and pipes."

    The 2021 USPSTF recommendation describes vaping as "the inhaling and exhaling of aerosols produced by e-cigarettes." In addition, it states, "vaping products (i.e., e-cigarettes) usually contain nicotine, which is the addictive ingredient in tobacco. Substances other than tobacco can also be used to smoke or vape. While the 2015 USPSTF recommendation statement used the term 'electronic nicotine delivery systems' or 'ENDS,' the USPSTF recognizes that the field has shifted to using the term 'e-cigarettes' (or 'e-cigs') and uses the term e-cigarettes in the current recommendation statement. e-Cigarettes can come in many shapes and sizes, but generally they heat a liquid that contains nicotine (the addictive drug in tobacco) to produce an aerosol (or 'vapor') that is inhaled ('vaped') by users."

    Tobacco Cessation Intervention - Includes brief counseling (3 minutes or less), and/or pharmacotherapy

    Note: Concepts aligned with brief counseling (e.g., minimal and intensive advice/counseling interventions conducted both in person and over the phone) are included in the value set for the numerator. Other concepts such as written self-help materials (e.g., brochures, pamphlets) and complementary/alternative therapies are not included in the value set and do not qualify for the numerator. Counseling also may be of longer duration or be performed more frequently, as evidence shows that higher-intensity interventions are associated with higher tobacco cessation rates (U.S. Preventive Services Task Force, 2021).
Guidance |
    The requirement of two or more visits is to establish that the eligible clinician has an existing relationship with the patient for certain types of encounters.

    To satisfy the intent of this measure, a patient must have at least one tobacco use screening during the measurement period. If a patient has multiple tobacco use screenings during the measurement 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 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.

    As noted above in the 2021 USPSTF recommendation statement, the current evidence is insufficient to recommend electronic cigarettes (e-cigarettes) for tobacco cessation. However, as noted above in the Definition section, the 2021 USPSTF recommendation also references the US Food and Drug Administration definition of tobacco, which includes e-cigarettes, hookah pens and other electronic nicotine delivery systems. Therefore, the measure does consider the use of e-cigarettes and other electronic nicotine delivery systems to be tobacco use.

    If a patient's tobacco use status is unknown, the patient does not meet the screening requirement and does not meet the numerator for populations 1 or 3. Instances where tobacco use status of "unknown" 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.

    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.

    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 a 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 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.

    This eCQM is a patient-based measure.

    This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.
Transmission Format |
    TBD
Initial Population |
    All patients aged 12 years and older seen for at least two visits or at least one preventive visit during the measurement period
Denominator |
    Population 1:
    Equals Initial Population

    Population 2:
    Equals Initial Population who were screened for tobacco use during the measurement period and identified as a tobacco user

    Population 3:
    Equals Initial Population
Denominator Exclusions |
    Exclude patients who are in hospice care for any part of the measurement period
Numerator |
    Population 1:
    Patients who were screened for tobacco use at least once during the measurement period

    Population 2:
    Patients who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period

    Population 3:
    Patients who were screened for tobacco use at least once during the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user
Numerator Exclusions |
    Not Applicable
Denominator Exceptions |
    None
Supplemental Data Elements |
    For every patient evaluated by this measure also identify payer, race, ethnicity and sex

## Table of Contents

- Population Criteria
- Definitions
- Functions
- Terminology
- Data Criteria (QDM Data Elements)
- Supplemental Data Elements
- Risk Adjustment Variables

### Population Criteria

- Population Criteria 1
  - - Initial Population

      - -     AgeInYearsAt(date from start of "Measurement Period")>= 12
                and ( Count("Qualifying Visit During Measurement Period")>= 2
                    or exists "Preventive Visit During Measurement Period"
                )

  - - Denominator

      - -     "Initial Population"

  - - Denominator Exclusions

      - -     Hospice."Has Hospice Services"

  - - Numerator

      - -     "Most Recent Tobacco Use Screening Indicates Tobacco Non User" is not null
                or "Most Recent Tobacco Use Screening Indicates Tobacco User" is not null

  - - Numerator Exclusions

      - -     None

  - - Denominator Exceptions

      - -     None

  - - Stratification

      - -     None

- Population Criteria 2
  - - Initial Population

      - -     AgeInYearsAt(date from start of "Measurement Period")>= 12
                and ( Count("Qualifying Visit During Measurement Period")>= 2
                    or exists "Preventive Visit During Measurement Period"
                )

  - - Denominator

      - -     "Initial Population"
                and "Most Recent Tobacco Use Screening Indicates Tobacco User" is not null

  - - Denominator Exclusions

      - -     Hospice."Has Hospice Services"

  - - Numerator

      - -     exists "Tobacco Cessation Counseling Given"
                or exists "Tobacco Cessation Pharmacotherapy Ordered"
                or exists "Active Pharmacotherapy for Tobacco Cessation"

  - - Numerator Exclusions

      - -     None

  - - Denominator Exceptions

      - -     None

  - - Stratification

      - -     None

- Population Criteria 3
  - - Initial Population

      - -     AgeInYearsAt(date from start of "Measurement Period")>= 12
                and ( Count("Qualifying Visit During Measurement Period")>= 2
                    or exists "Preventive Visit During Measurement Period"
                )

  - - Denominator

      - -     "Initial Population"

  - - Denominator Exclusions

      - -     Hospice."Has Hospice Services"

  - - Numerator

      - -     "Most Recent Tobacco Use Screening Indicates Tobacco Non User" is not null
                or ( "Most Recent Tobacco Use Screening Indicates Tobacco User" is not null
                    and ( exists "Tobacco Cessation Counseling Given"
                        or exists "Tobacco Cessation Pharmacotherapy Ordered"
                        or exists "Active Pharmacotherapy for Tobacco Cessation"
                    )
                )

  - - Numerator Exclusions

      - -     None

  - - Denominator Exceptions

      - -     None

  - - Stratification

      - -     None

### Definitions

- - Active Pharmacotherapy for Tobacco Cessation

    - -     ["Medication, Active": "Tobacco Use Cessation Pharmacotherapy"] TakingCessationPharmacotherapy
              where Global."NormalizeInterval" ( TakingCessationPharmacotherapy.relevantDatetime, TakingCessationPharmacotherapy.relevantPeriod ) during day of Interval[start of "Measurement Period" - 6 months,
              end of "Measurement Period"]

  - Denominator 1

    - -     "Initial Population"

  - Denominator 2

    - -     "Initial Population"
              and "Most Recent Tobacco Use Screening Indicates Tobacco User" is not null

  - Denominator 3

    - -     "Initial Population"

  - Denominator Exclusion

    - -     Hospice."Has Hospice Services"

  - Hospice.Has Hospice Services

    - -     exists ( ["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter
                where ( InpatientEncounter.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
                    or InpatientEncounter.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"
                )
                  and InpatientEncounter.relevantPeriod ends during day of "Measurement Period"
            )
              or exists ( ["Encounter, Performed": "Hospice Encounter"] HospiceEncounter
                  where HospiceEncounter.relevantPeriod overlaps day of "Measurement Period"
              )
              or exists ( ["Assessment, Performed": "Hospice care [Minimum Data Set]"] HospiceAssessment
                  where HospiceAssessment.result ~ "Yes (qualifier value)"
                    and Global."NormalizeInterval" ( HospiceAssessment.relevantDatetime, HospiceAssessment.relevantPeriod ) overlaps day of "Measurement Period"
              )
              or exists ( ["Intervention, Order": "Hospice Care Ambulatory"] HospiceOrder
                  where HospiceOrder.authorDatetime during day of "Measurement Period"
              )
              or exists ( ["Intervention, Performed": "Hospice Care Ambulatory"] HospicePerformed
                  where Global."NormalizeInterval" ( HospicePerformed.relevantDatetime, HospicePerformed.relevantPeriod ) overlaps day of "Measurement Period"
              )
            or exists ( ["Diagnosis": "Hospice Diagnosis"] HospiceCareDiagnosis
                  where HospiceCareDiagnosis.prevalencePeriod overlaps day of "Measurement Period"
              )

  - Initial Population

    - -     AgeInYearsAt(date from start of "Measurement Period")>= 12
              and ( Count("Qualifying Visit During Measurement Period")>= 2
                  or exists "Preventive Visit During Measurement Period"
              )

  - Most Recent Tobacco Use Screening Indicates Tobacco Non User

    - -     ( Last(["Assessment, Performed": "Tobacco Use Screening"] TobaccoUseScreening
                where Global."NormalizeInterval"(TobaccoUseScreening.relevantDatetime, TobaccoUseScreening.relevantPeriod)during day of "Measurement Period"
                sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
            )) MostRecentTobaccoUseScreening
              where MostRecentTobaccoUseScreening.result in "Tobacco Non User"

  - Most Recent Tobacco Use Screening Indicates Tobacco User

    - -     ( Last(["Assessment, Performed": "Tobacco Use Screening"] TobaccoUseScreening
                where Global."NormalizeInterval"(TobaccoUseScreening.relevantDatetime, TobaccoUseScreening.relevantPeriod)during day of "Measurement Period"
                sort by start of Global."NormalizeInterval"(relevantDatetime, relevantPeriod)
            )) MostRecentTobaccoUseScreening
              where MostRecentTobaccoUseScreening.result in "Tobacco User"

  - Numerator 1

    - -     "Most Recent Tobacco Use Screening Indicates Tobacco Non User" is not null
              or "Most Recent Tobacco Use Screening Indicates Tobacco User" is not null

  - Numerator 2

    - -     exists "Tobacco Cessation Counseling Given"
              or exists "Tobacco Cessation Pharmacotherapy Ordered"
              or exists "Active Pharmacotherapy for Tobacco Cessation"

  - Numerator 3

    - -     "Most Recent Tobacco Use Screening Indicates Tobacco Non User" is not null
              or ( "Most Recent Tobacco Use Screening Indicates Tobacco User" is not null
                  and ( exists "Tobacco Cessation Counseling Given"
                      or exists "Tobacco Cessation Pharmacotherapy Ordered"
                      or exists "Active Pharmacotherapy for Tobacco Cessation"
                  )
              )

  - Preventive Visit During Measurement Period

    - -     ( ["Encounter, Performed": "Annual Wellness Visit"]
              union ["Encounter, Performed": "Preventive Care Services Established Office Visit, 18 and Up"]
              union ["Encounter, Performed": "Preventive Care Services Group Counseling"]
              union ["Encounter, Performed": "Unlisted preventive medicine service"]
              union ["Encounter, Performed": "Preventive Care Services Individual Counseling"]
              union ["Encounter, Performed": "Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure"]
              union ["Encounter, Performed": "Nutrition Services"]
              union ["Encounter, Performed": "Preventive Care Services Initial Office Visit, 18 and Up"] ) PreventiveEncounter
              where PreventiveEncounter.relevantPeriod during day of "Measurement Period"

  - Qualifying Visit During Measurement Period

    - -     ( ["Encounter, Performed": "Health behavior intervention, individual, face-to-face; initial 30 minutes"]
              union ["Encounter, Performed": "Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making)"]
              union ["Encounter, Performed": "Home Healthcare Services"]
              union ["Encounter, Performed": "Occupational Therapy Evaluation"]
              union ["Encounter, Performed": "Office Visit"]
              union ["Encounter, Performed": "Ophthalmological Services"]
              union ["Encounter, Performed": "Physical Therapy Evaluation"]
              union ["Encounter, Performed": "Psych Visit Diagnostic Evaluation"]
              union ["Encounter, Performed": "Psych Visit Psychotherapy"]
              union ["Encounter, Performed": "Psychoanalysis"]
              union ["Encounter, Performed": "Speech and Hearing Evaluation"]
              union ["Encounter, Performed": "Telephone Visits"]
              union ["Encounter, Performed": "Online Assessments"] ) OfficeBasedEncounter
              where OfficeBasedEncounter.relevantPeriod during day of "Measurement Period"

  - SDE Ethnicity

    - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

  - SDE Payer

    - -     ["Patient Characteristic Payer": "Payer"]

  - SDE Race

    - -     ["Patient Characteristic Race": "Race"]

  - SDE Sex

    - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

  - Tobacco Cessation Counseling Given

    - -     ( ["Intervention, Performed": "Tobacco Use Cessation Counseling"] TobaccoCessationCounseling
                where Global."NormalizeInterval" ( TobaccoCessationCounseling.relevantDatetime, TobaccoCessationCounseling.relevantPeriod ) during day of Interval[start of "Measurement Period" - 6 months,
                end of "Measurement Period"]
            )
              union ( ["Diagnosis": "Tobacco abuse counseling"] TobaccoCounseling
                  where ( TobaccoCounseling.prevalencePeriod ) starts during day of Interval[start of "Measurement Period" - 6 months,
                  end of "Measurement Period"]
              )

  - Tobacco Cessation Pharmacotherapy Ordered

    - -     ["Medication, Order": "Tobacco Use Cessation Pharmacotherapy"] CessationPharmacotherapyOrdered
              where CessationPharmacotherapyOrdered.authorDatetime during day of Interval[start of "Measurement Period" - 6 months,
              end of "Measurement Period"]

### Functions

- - Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

    - -     if pointInTime is not null then Interval[pointInTime, pointInTime]
              else if period is not null then period
              else null as Interval<DateTime>

### Terminology

- code "Discharge to healthcare facility for hospice care (procedure)" ("SNOMEDCT Code (428371000124100)")
- code "Discharge to home for hospice care (procedure)" ("SNOMEDCT Code (428361000124107)")
- code "Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making)" ("CPT Code (96156)")
- code "Health behavior intervention, individual, face-to-face; initial 30 minutes" ("CPT Code (96158)")
- code "Hospice care [Minimum Data Set]" ("LOINC Code (45755-6)")
- code "Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure" ("CPT Code (99024)")
- code "Tobacco abuse counseling" ("ICD10CM Code (Z71.6)")
- code "Unlisted preventive medicine service" ("CPT Code (99429)")
- code "Yes (qualifier value)" ("SNOMEDCT Code (373066001)")
- valueset "Annual Wellness Visit" (2.16.840.1.113883.3.526.3.1240)
- valueset "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307)
- valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
- valueset "Home Healthcare Services" (2.16.840.1.113883.3.464.1003.101.12.1016)
- valueset "Hospice Care Ambulatory" (2.16.840.1.113883.3.526.3.1584)
- valueset "Hospice Diagnosis" (2.16.840.1.113883.3.464.1003.1165)
- valueset "Hospice Encounter" (2.16.840.1.113883.3.464.1003.1003)
- valueset "Nutrition Services" (2.16.840.1.113883.3.464.1003.1006)
- valueset "Occupational Therapy Evaluation" (2.16.840.1.113883.3.526.3.1011)
- valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001)
- valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
- valueset "Online Assessments" (2.16.840.1.113883.3.464.1003.101.12.1089)
- valueset "Ophthalmological Services" (2.16.840.1.113883.3.526.3.1285)
- valueset "Payer" (2.16.840.1.114222.4.11.3591)
- valueset "Physical Therapy Evaluation" (2.16.840.1.113883.3.526.3.1022)
- valueset "Preventive Care Services Established Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1025)
- valueset "Preventive Care Services Group Counseling" (2.16.840.1.113883.3.464.1003.101.12.1027)
- valueset "Preventive Care Services Individual Counseling" (2.16.840.1.113883.3.464.1003.101.12.1026)
- valueset "Preventive Care Services Initial Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1023)
- valueset "Psych Visit Diagnostic Evaluation" (2.16.840.1.113883.3.526.3.1492)
- valueset "Psych Visit Psychotherapy" (2.16.840.1.113883.3.526.3.1496)
- valueset "Psychoanalysis" (2.16.840.1.113883.3.526.3.1141)
- valueset "Race" (2.16.840.1.114222.4.11.836)
- valueset "Speech and Hearing Evaluation" (2.16.840.1.113883.3.526.3.1530)
- valueset "Telephone Visits" (2.16.840.1.113883.3.464.1003.101.12.1080)
- valueset "Tobacco Non User" (2.16.840.1.113883.3.526.3.1189)
- valueset "Tobacco Use Cessation Counseling" (2.16.840.1.113883.3.526.3.509)
- valueset "Tobacco Use Cessation Pharmacotherapy" (2.16.840.1.113883.3.526.3.1190)
- valueset "Tobacco Use Screening" (2.16.840.1.113883.3.526.3.1278)
- valueset "Tobacco User" (2.16.840.1.113883.3.526.3.1170)

### Data Criteria (QDM Data Elements)

- "Assessment, Performed: Hospice care [Minimum Data Set]" using "Hospice care [Minimum Data Set] (LOINC Code 45755-6)"
- "Assessment, Performed: Tobacco Use Screening" using "Tobacco Use Screening (2.16.840.1.113883.3.526.3.1278)"
- "Diagnosis: Hospice Diagnosis" using "Hospice Diagnosis (2.16.840.1.113883.3.464.1003.1165)"
- "Diagnosis: Tobacco abuse counseling" using "Tobacco abuse counseling (ICD10CM Code Z71.6)"
- "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit (2.16.840.1.113883.3.526.3.1240)"
- "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient (2.16.840.1.113883.3.666.5.307)"
- "Encounter, Performed: Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making)" using "Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making) (CPT Code 96156)"
- "Encounter, Performed: Health behavior intervention, individual, face-to-face; initial 30 minutes" using "Health behavior intervention, individual, face-to-face; initial 30 minutes (CPT Code 96158)"
- "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services (2.16.840.1.113883.3.464.1003.101.12.1016)"
- "Encounter, Performed: Hospice Encounter" using "Hospice Encounter (2.16.840.1.113883.3.464.1003.1003)"
- "Encounter, Performed: Nutrition Services" using "Nutrition Services (2.16.840.1.113883.3.464.1003.1006)"
- "Encounter, Performed: Occupational Therapy Evaluation" using "Occupational Therapy Evaluation (2.16.840.1.113883.3.526.3.1011)"
- "Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
- "Encounter, Performed: Online Assessments" using "Online Assessments (2.16.840.1.113883.3.464.1003.101.12.1089)"
- "Encounter, Performed: Ophthalmological Services" using "Ophthalmological Services (2.16.840.1.113883.3.526.3.1285)"
- "Encounter, Performed: Physical Therapy Evaluation" using "Physical Therapy Evaluation (2.16.840.1.113883.3.526.3.1022)"
- "Encounter, Performed: Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure" using "Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure (CPT Code 99024)"
- "Encounter, Performed: Preventive Care Services Established Office Visit, 18 and Up" using "Preventive Care Services Established Office Visit, 18 and Up (2.16.840.1.113883.3.464.1003.101.12.1025)"
- "Encounter, Performed: Preventive Care Services Group Counseling" using "Preventive Care Services Group Counseling (2.16.840.1.113883.3.464.1003.101.12.1027)"
- "Encounter, Performed: Preventive Care Services Individual Counseling" using "Preventive Care Services Individual Counseling (2.16.840.1.113883.3.464.1003.101.12.1026)"
- "Encounter, Performed: Preventive Care Services Initial Office Visit, 18 and Up" using "Preventive Care Services Initial Office Visit, 18 and Up (2.16.840.1.113883.3.464.1003.101.12.1023)"
- "Encounter, Performed: Psych Visit Diagnostic Evaluation" using "Psych Visit Diagnostic Evaluation (2.16.840.1.113883.3.526.3.1492)"
- "Encounter, Performed: Psych Visit Psychotherapy" using "Psych Visit Psychotherapy (2.16.840.1.113883.3.526.3.1496)"
- "Encounter, Performed: Psychoanalysis" using "Psychoanalysis (2.16.840.1.113883.3.526.3.1141)"
- "Encounter, Performed: Speech and Hearing Evaluation" using "Speech and Hearing Evaluation (2.16.840.1.113883.3.526.3.1530)"
- "Encounter, Performed: Telephone Visits" using "Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080)"
- "Encounter, Performed: Unlisted preventive medicine service" using "Unlisted preventive medicine service (CPT Code 99429)"
- "Intervention, Order: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
- "Intervention, Performed: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
- "Intervention, Performed: Tobacco Use Cessation Counseling" using "Tobacco Use Cessation Counseling (2.16.840.1.113883.3.526.3.509)"
- "Medication, Active: Tobacco Use Cessation Pharmacotherapy" using "Tobacco Use Cessation Pharmacotherapy (2.16.840.1.113883.3.526.3.1190)"
- "Medication, Order: Tobacco Use Cessation Pharmacotherapy" using "Tobacco Use Cessation Pharmacotherapy (2.16.840.1.113883.3.526.3.1190)"
- "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
- "Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
- "Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
- "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"

### Supplemental Data Elements

- SDE Ethnicity

  - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

- SDE Payer

  - -     ["Patient Characteristic Payer": "Payer"]

- SDE Race

  - -     ["Patient Characteristic Race": "Race"]

- SDE Sex

  - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

### Risk Adjustment Variables

- None

Measure Set |
    None