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

General eCQM Information

CMS Measure ID CMS138v9
NQF Number 0028e
Measure Description

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 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 12 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 12 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 12 months

 

Population 2:

Patients who received tobacco cessation intervention

Population 3:

Patients who were screened for tobacco use at least once within 12 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)

Measure Steward PCPI(R) Foundation (PCPI[R])
Domain Community/Population Health
Measure Scoring Proportion measure
Measure Type Process measure
Improvement Notation

Higher score indicates better quality

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 12-month period. If a patient has multiple tobacco use screenings during the 12-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 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.

Quality ID 226
Meaningful Measure Prevention and Treatment of Opioid and Substance Use Disorders
Telehealth Eligible Yes
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Release Notes

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Revised description to reflect a reduced timeframe for screening a patient for tobacco use and providing an intervention, as appropriate, based upon external and clinical expert feedback.

    Measure Section: Description

    Source of Change: Expert Work Group Review

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated disclaimer.

    Measure Section: Disclaimer

    Source of Change: Standards Update

  • Updated reference to align with American Psychological Association (APA) formatting.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Added text to identify the Quality Data Model (QDM) version used in the measure specification.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Added text to indicate whether the measure is patient-based or episode-based.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Reordered guidance statements to follow the order in which they will need to be considered for implementation with the goal of improving clarity and understanding of the measure intent.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Revised guidance to reflect a reduced timeframe for screening a patient for tobacco use, based upon external and clinical expert feedback, including how to handle multiple screenings during that timeframe.

    Measure Section: Guidance

    Source of Change: Expert Work Group Review

  • Revised numerator language to reflect a reduced timeframe for: screening a patient for tobacco use (population 1) AND screening a patient for tobacco use and providing an intervention, as appropriate (population 3), based upon external and clinical expert feedback.

    Measure Section: Numerator

    Source of Change: Expert Work Group Review

Logic

  • Added new data element to allow for Physical Therapy Evaluation as an eligible encounter, per specialty society request.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Revised timeframe from 24 months to 12 months for tobacco use screening in population 2 denominator, based upon external and clinical expert feedback.

    Measure Section: Denominator

    Source of Change: Expert Work Group Review

  • Revised timeframe from 24 months to 12 months for tobacco use screening in the numerator for populations 1 and 3, based upon external and clinical expert feedback. Revised timing associated with performing a tobacco cessation intervention in the numerator for populations 2 and 3, to remove the constraint that these actions must occur after the most recent tobacco use screening during which the patient was identified as a tobacco user, and ties these actions to the measurement period.

    Measure Section: Numerator

    Source of Change: Expert Work Group Review

  • Added new data element to allow for Physical Therapy Evaluation as an eligible encounter, per specialty society request.

    Measure Section: Definitions

    Source of Change: Measure Lead

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

    Measure Section: Definitions

    Source of Change: Standards Update

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

    Measure Section: Functions

    Source of Change: Standards Update

  • Updated CQL definition names and aliases used to more closely align with clinical concept intent or create consistency of naming across measures.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated CQL expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000). Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

    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 Medical Reason (2.16.840.1.113883.3.526.3.1007): Deleted 5 SNOMED CT codes (216952002, 274512008, 371133007, 416406003, 445528004) based on expert review and/or public feedback. Removed codes due to intent of concepts which do not indicate a medical contraindication, but rather a provider decision to discontinue something or change a course of treatment.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Psych Visit - Diagnostic Evaluation (2.16.840.1.113883.3.526.3.1492): Deleted 1 SNOMED CT code (32537008) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Physical Therapy Evaluation (2.16.840.1.113883.3.526.3.1022): Added Physical Therapy Evaluation based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Specialty Request

  • Replaced value set Health & Behavioral Assessment - Individual (2.16.840.1.113883.3.526.3.1020) with direct reference code CPT code (96156) to align with best practices for replacing single code value sets with direct reference codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced value set Health and Behavioral Assessment - Initial (2.16.840.1.113883.3.526.3.1245) with direct reference code CPT code (96158) to align with best practices for replacing single code value sets with direct reference codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced value set Health and Behavioral Assessment, Reassessment (2.16.840.1.113883.3.526.3.1529) with direct reference code CPT code (96156) to align with best practices for replacing single code value sets with direct reference codes.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: May 05, 2021