download chevron-down chevron-right chevron-with-circle-down chevron-with-circle-up check circle-with-minus circle-with-plus export help-with-circle inbox link mail old-phone star-outlined star user v-card close close close Back to top
Top
Top of Content

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

Last updated: May 16, 2019

CMS Measure ID: CMS138v4
Version: 4
NQF Number: 0028
Measure Description:

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

Initial Population:

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

Denominator Statement:

Equals Initial Populationinfo-icon

Denominator Exclusions:

None

Numerator Statement:

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

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

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

Measure Steward: American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI)
Domain: Community/Population Health
Next Version:
Measure Scoring: Proportion
Improvement Notation:

Higher score indicates better quality

Guidance:

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

If tobacco use status of a patient is unknown, the patient does not meet the screening component required to be counted in the numeratorinfo-icon 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 denominatorinfo-icon of the measure and reported as a valid exception.

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

Specifications

Release Notes

Header

  • Copyright updated.
  • Definition updated.
  • Disclaimer updated.
  • eMeasure version number incremented.
  • Guidance updated.
  • Numeratorinfo-icon statement updated.

Logic

  • Added timing constraint to each logic clause in numerator.
  • Health and Behavioral Assessment, Reassessment data element added to measure.
  • Introduced function 'satisfies all' to specify that qualifying events must meet all conditions from a set of conditions or 'satisfies any' to specify that qualifying events must meet at least one condition from a set of conditions to streamline expression logic.
  • Replaced 'Measurement Start Date' and 'Measurement End Date' with 'Measurement Period' and as necessary, replaced existing timing operator (e.g., replacing 'starts before start of' with 'starts before end of').
  • Replaced 'ORs' with 'Union of' operator to provide a mechanism to specify that qualifying event(s) must be a member of at least one of the data elements being unioned (if appropriate for measure intent).
  • Replaced 'Patient Characteristic Birthdate' with 'Age at' operator.
  • Replaced 'starts before or during' (SBOD) with 'starts before end of' (SBE).
  • Speech and Hearing Evaluation data element added to measure.
  • The top level logical operator for the Numerator Exclusionsinfo-icon, Denominator Exclusionsinfo-icon, Denominator Exceptionsinfo-icon, and Measure Population Exclusions defaults to 'OR'.
  • Updated exception logic to designate ‘Limited Life Expectancy’ as a reason for not performing the ‘Risk Category Assessment: Tobacco Use Screening’.

Value Setsinfo-icon

  • Value setinfo-icon Health and Behavioral Assessment, Reassessment (OID 2.16.840.1.113883.3.526.3.1529): Added value set to measure.
  • Value set Speech and Hearing Evaluation (OID 2.16.840.1.113883.3.526.3.1530): Added value set to measure.
  • Value set Tobacco Use Screening (OID 2.16.840.1.113883.3.526.3.1278): Deleted 1 LOINC code (11366-2), added 2 LOINC codes (72166-2, 39240-7).

External Resources