Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
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| Measure Information | 2022 Performance Period | 2023 Performance Period | 2024 Performance Period | 2025 Performance Period |
|---|---|---|---|---|
| Title | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
| CMS eCQM ID | CMS138v10 | CMS138v11 | CMS138v12 | CMS138v13 |
| CBE ID* | 0028e | 0028e | Not Applicable | Not Applicable |
| MIPS Quality ID | 226 | 226 | 226 | 226 |
| Measure Steward | National Committee for Quality Assurance | National Committee for Quality Assurance | National Committee for Quality Assurance | National Committee for Quality Assurance |
| Description |
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times during the measurement period 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 during the measurement period 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 during the measurement period AND who received tobacco cessation intervention if identified as a tobacco user |
Percentage of patients aged 18 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 18 years and older who were screened for tobacco use one or more times during the measurement period b. Percentage of patients aged 18 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 18 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 |
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 |
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 |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process | Process | Process | Process |
| Stratification | *See CMS138v10.html | *See CMS138v11.html |
None |
None |
| Risk Adjustment | *See CMS138v10.html | *See CMS138v11.html |
None |
None |
| Rationale | *See CMS138v10.html | *See CMS138v11.html |
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. |
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 | *See CMS138v10.html | *See CMS138v11.html |
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). |
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 |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
| Definition | *See CMS138v10.html | *See CMS138v11.html |
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). |
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 professional or 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 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. 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. 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. 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. 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. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
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 QDM page for more information on the QDM. |
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 QDM page for more information on the QDM. |
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 QDM page for more information on the QDM. |
| 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 |
All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period |
All patients aged 12 years and older seen for at least two visits or at least one preventive visit during the measurement period |
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 and identified as a tobacco user Population 3: Equals Initial Population |
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 |
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 |
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 |
None |
Exclude patients who are in hospice care for any part of the measurement period |
Exclude patients who are in hospice care for any part of the measurement period |
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 Population 3: Patients who were screened for tobacco use at least once during the measurement period AND who received tobacco cessation intervention if identified as a tobacco user |
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 |
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 |
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 |
Not Applicable |
Not Applicable |
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) |
None |
None |
None |
| Telehealth Eligible | Yes | Yes | Yes | Yes |
| Next Version | No Version Available | |||
| Previous Version | No Version Available |
Additional Resources for CMS138v11
Header
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
Updated references.
Measure Section: Reference
Source of Change: Measure Lead
Updated the guidance language to align with 2021 US Preventive Services Task Force (USPSTF) recommendations.
Measure Section: Guidance
Source of Change: ONC Project Tracking System (JIRA): CQM-4576
Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.
Measure Section: Guidance
Source of Change: Standards/Technical Update
Revised the denominator statement for population 2 to clarify the timing of the tobacco use screening and align with the logic.
Measure Section: Denominator
Source of Change: Measure Lead
Updated the timing requirement for the tobacco cessation interventions to allow for greater flexibility in implementation and to capture more patients in the numerator.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Updated the definition and clinical recommendation statement language to align with 2021 USPSTF recommendations.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Removed the header language for denominator exceptions and added denominator exclusions to exclude patients who are receiving hospice care to meet the clinical intent of the measure.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Updated grammar and punctuation to improve readability.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Logic
Updated the timing precision in the definitions from datetime to date by adding 'day of', 'date from', and/or function 'ToDateInterval' to align with the measure intent.
Measure Section: Definitions
Source of Change: Measure Lead
Updated the numerator definitions to allow for a 6-month lookback prior to the current measurement period for tobacco cessation interventions to allow for greater flexibility in implementation and to capture more patients in the numerator.
Measure Section: Definitions
Source of Change: Measure Lead
Updated the logic to include dietician visits as eligible encounters for the denominator.
Measure Section: Definitions
Source of Change: Measure Lead
Updated the logic to include an additional 'Diagnosis' QDM datatype to meet numerator compliance.
Measure Section: Definitions
Source of Change: ONC Project Tracking System (JIRA): CQM-4358
Updated the logic to add postoperative follow-up visit as an eligible encounter.
Measure Section: Definitions
Source of Change: ONC Project Tracking System (JIRA): CQM-2639
Replaced value set Preventive Care Services Other (2.16.840.1.113883.3.464.1003.101.12.1030) with direct reference code CPT code (99429).
Measure Section: Definitions
Source of Change: Measure Lead
Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Added Hospice Library v4.0.000.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Removed denominator exceptions logic and added denominator exclusion logic to exclude patients who are receiving hospice care to meet the clinical intent of the measure.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Value set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
Added direct reference code CPT code (99024) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added direct reference code LOINC code (45755-6) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added direct reference code SNOMED CT code (428361000124107) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added direct reference code SNOMED CT code (428371000124100) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Tobacco Use Cessation Pharmacotherapy (2.16.840.1.113883.3.526.3.1190): Added 1 RxNorm code (1313059) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Physical Therapy Evaluation (2.16.840.1.113883.3.526.3.1022): Added 6 SNOMED CT codes (410158009, 410160006, 183326003, 410159001, 424203006, 424291000) based on review by technical experts, SMEs, and/or public feedback. Added 1 CPT code (97164) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Occupational Therapy Evaluation (2.16.840.1.113883.3.526.3.1011): Added 6 SNOMED CT codes (228653003, 410156008, 423602000, 424574000, 59694001, 84478008) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set Limited Life Expectancy (2.16.840.1.113883.3.526.3.1259) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Removed value set Medical Reason (2.16.840.1.113883.3.526.3.1007) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Replaced value set Preventive Care Services - Other (2.16.840.1.113883.3.464.1003.101.12.1030) with direct reference code CPT code (99429) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Nutrition Services (2.16.840.1.113883.3.464.1003.1006) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Hospice Encounter (2.16.840.1.113883.3.464.1003.1003) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set (2.16.840.1.113883.3.526.3.1189): Renamed to Tobacco Non User based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Value set (2.16.840.1.113883.3.464.1003.101.12.1026): Renamed to Preventive Care Services Individual Counseling based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Value set (2.16.840.1.113883.3.464.1003.101.12.1027): Renamed to Preventive Care Services Group Counseling based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Value set (2.16.840.1.113883.3.526.3.1496): Renamed to Psych Visit Psychotherapy based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Value set (2.16.840.1.113883.3.526.3.1492): Renamed to Psych Visit Diagnostic Evaluation based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Value set (2.16.840.1.113883.3.464.1003.101.12.1023): Renamed to Preventive Care Services Initial Office Visit, 18 and Up based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Value set (2.16.840.1.113883.3.464.1003.101.12.1025): Renamed to Preventive Care Services Established Office Visit, 18 and Up based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Added direct reference code ICD-10-CM code (Z71.6) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Encounter Inpatient (2.16.840.1.113883.3.666.5.307) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added direct reference code SNOMED CT code (373066001) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead