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

Last updated: September 14, 2018

CMS Measure ID: CMS138v7
Version: 7
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 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 24 months

b. Percentage of patients aged 18 years and older who were screened for tobacco use and 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 24 months AND who received tobacco cessation intervention if identified as a tobacco user

Initial Patient Population:

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

Denominator Statement:

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 24 months

Population 2:

Patients who received tobacco cessation intervention

Population 3:

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:

Population 1:

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

Population 2:

Documentation of medical reason(s) for not providing tobacco cessation intervention (eg, 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 (eg, limited life expectancy, other medical reason)

Measure Steward: PCPI(R) Foundation (PCPI[R])
Domain: Community/Population Health
Previous Version:
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.

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.

If a patient has multiple tobacco use screenings during the 24-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 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.

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.

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.

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.

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 prior published versions of this measure.

Quality ID: 226
Meaningful Measure: Prevention and Treatment of Opioid and Substance Use Disorders

Specifications

Release Notes

Header

  • Updated Version Number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated Disclaimer.

    Measure Section: Disclaimer

    Source of Change: Measure Lead

  • ​​Updated Guidance statement regarding two or more visits to remove reference to QDM expression logic.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Added Guidance to provide clarification for numerator accountability based on clinical experts' feedback.

    Measure Section: Guidance

    Source of Change: Measure Lead

Logic

  • Added 'AuthorDateTime' attribute to QDM datatypes that include negation rationale: ‘Diagnostic, Performed’, ‘Intervention Performed’, ‘Encounter, Performed’, ‘Laboratory Test, Performed’, ‘Medication, Administered’, ‘Physical Exam, Performed’, ‘Procedure, Performed’, ‘Substance Administered’ to conform with QDM 5.3 changes.

    Measure Section: Denominator Exceptions

    Source of Change: Standards Update

  • Added supplemental timing attributes to most datatypes in QDM 5.3 to facilitate accurate retrieval of time related information within CQL logic. Timing attributes now include a time interval, such as prevalence period or relevant period, and/or actual time of documentation with Author Datetime. Relevant period is the general method to describe start and stop times for datatypes. Prevalence period is used for some datatypes to more accurately define onset and abatement times.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Assigned cardinality to each attribute to be more explicit in guiding specification and implementation of QDM data elements. Cardinality refers to the number of instances of the attribute that can be included in the measure description. Cardinality for most attributes is 0.. 1 (i.e., can occur up to 1 time), but some attributes have a cardinality of 0.. * (i.e., can occur multiple times).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • CQL libraries contain sets of CQL definitions, or CQL expression statements. A context statement, patient or population, can now be used in a CQL library to clearly establish how the subsequent list of CQL expressions will be interpreted. A 'Population' context will interpret the CQL expression with reference to the entire population of the item being counted, patients or encounters. A 'Patient' context will interpret the CQL expression with reference to a single patient. Context statements are not required, but one or more context statements may be used within a library to help clarify how the CQL expressions will be interpreted. Patient context is the default if none is specified.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Removed the 'Face-To-Face Interaction' data element and added relevant SNOMED codes to the Encounter Grouping value sets to better align between the SNOMED and CPT encounter codes.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Replaced measure-defined definitions with similar definitions and functions from CQL shared libraries for consistency across measures.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated measure logic from Quality Data Model (QDM)-based logic to Clinical Quality Language (CQL)-based logic. Information on CQL can be found at the eCQI Resource center (https://ecqi.healthit.gov/cql). Information about specific versions of the new standards in use for CMS reporting periods can be found at the eCQI Resource Center (https://ecqi.healthit.gov/ecqm-tools-key-resources). Switching from QDM to CQL brings with it many changes, as well as enhanced expression capability, but only those changes with significant impact will be outlined in technical release notes. For example, in the case of timing operators, changes may only be summarized if those changes impact the measure calculation.

    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 Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001): Added SNOMEDCT extensional value set (2.16.840.1.113883.3.464.1003.101.11.1264) including 7 codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Home Healthcare Services (2.16.840.1.113883.3.464.1003.101.12.1016): Added SNOMEDCT extensional value set (2.16.840.1.113883.3.464.1003.101.11.1265) including 11 codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 11 SOP codes (299, 32127, 32128, 391, 517, 524, 614, 621, 622, 623, 629) and deleted 3 SOP codes (63, 64, 69).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Face-to-Face Interaction (2.16.840.1.113883.3.464.1003.101.12.1048): Removed Face-to-Face Interaction.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Limited Life Expectancy (2.16.840.1.113883.3.526.3.1259): Added 1 SNOMEDCT code (111947009).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Payer (2.16.840.1.114222.4.11.3591): Deleted 1 SOP code (24).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

External Resources