Measure: CMS138
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Measure Versions
| eMeasure Code |
Measure Year |
Full Version Number |
Title |
| CMS138v12 |
2024 |
12.0.000 |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
| CMS138v11 |
2023 |
11 |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
| CMS138v10 |
2022 |
10.0.000 |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
| CMS138v9 |
2021 |
9.2.000 |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
| CMS138v8 |
2020 |
8.1.000 |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
| CMS138v7 |
2019 |
7.1.000 |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
| CMS138v6 |
2018 |
6.1.000 |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
| CMS138v5 |
2017 |
5.0.000 |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
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
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 (https://ecqi.healthit.gov/qdm) for more information on the QDM.
Patient Group Definitions
| Group |
Description |
Instructions Links |
| 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 | Webchart Instructions |
| 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 | Webchart Instructions |
| Denominator Exclusions | None | |
| 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 | Webchart Instructions |
| Numerator Exclusions | Not Applicable | Webchart Instructions |
| 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) | Webchart Instructions |
Details
| Full eMeasure Code |
eMeasure Identifier |
Measure Year |
Version |
NQF # |
GUID |
| CMS138v10 |
|
2022 |
10.0.000 |
0028e |
e35791df-5b25-41bb-b260-673337bc44a8 |
| Steward |
Developer |
Endorsed By |
| National Committee for Quality Assurance |
National Committee for Quality Assurance |
National Quality Forum |
| Scoring Method |
Measure Type |
Stratification |
Risk Adjustment |
| Proportion |
PROCESS |
None |
None |
Rate Aggregation
None
Improvement Notation
Higher score indicates better quality
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 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 adults who use tobacco (Grade A Recommendation) (U.S. Preventive Services Task Force, 2015).
The USPSTF recommends that clinicians ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco (Grade A Recommendation) (U.S. Preventive Services Task Force, 2015).
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, 2015).
The USPSTF concludes that the current evidence is insufficient to recommend electronic nicotine delivery systems for tobacco cessation in adults, including pregnant women. The USPSTF recommends that clinicians direct patients who smoke tobacco to other cessation interventions with established effectiveness and safety (previously stated) (Grade I Statement) (U.S. Preventive Services Task Force, 2015).
Definition
Tobacco Use - Includes any type of tobacco
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. Brief counseling also may be of longer duration or be performed more frequently, as evidence shows there is a dose-response relationship between the intensity of counseling provided (either length or frequency) and tobacco cessation rates (U.S. Preventive Services Task Force, 2015).
Transmission Format
TBD
Applicable Value Sets
| Category |
Value Set |
OID |
| Assessment, Not Performed |
Tobacco Use Screening |
2.16.840.1.113883.3.526.3.1278 |
| Assessment, Performed |
Tobacco Use Screening |
2.16.840.1.113883.3.526.3.1278 |
| Diagnosis |
Limited Life Expectancy |
2.16.840.1.113883.3.526.3.1259 |
| Encounter, Performed |
Annual Wellness Visit |
2.16.840.1.113883.3.526.3.1240 |
| Encounter, Performed |
Home Healthcare Services |
2.16.840.1.113883.3.464.1003.101.12.1016 |
| Encounter, Performed |
Occupational Therapy Evaluation |
2.16.840.1.113883.3.526.3.1011 |
| Encounter, Performed |
Office Visit |
2.16.840.1.113883.3.464.1003.101.12.1001 |
| Encounter, Performed |
Online Assessments |
2.16.840.1.113883.3.464.1003.101.12.1089 |
| Encounter, Performed |
Ophthalmological Services |
2.16.840.1.113883.3.526.3.1285 |
| Encounter, Performed |
Physical Therapy Evaluation |
2.16.840.1.113883.3.526.3.1022 |
| Encounter, Performed |
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 |
2.16.840.1.113883.3.464.1003.101.12.1027 |
| Encounter, Performed |
Preventive Care Services - Other |
2.16.840.1.113883.3.464.1003.101.12.1030 |
| Encounter, Performed |
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 |
2.16.840.1.113883.3.464.1003.101.12.1023 |
| Encounter, Performed |
Psych Visit - Diagnostic Evaluation |
2.16.840.1.113883.3.526.3.1492 |
| Encounter, Performed |
Psych Visit - Psychotherapy |
2.16.840.1.113883.3.526.3.1496 |
| Encounter, Performed |
Psychoanalysis |
2.16.840.1.113883.3.526.3.1141 |
| Encounter, Performed |
Speech and Hearing Evaluation |
2.16.840.1.113883.3.526.3.1530 |
| Encounter, Performed |
Telephone Visits |
2.16.840.1.113883.3.464.1003.101.12.1080 |
| Intervention, Not Performed |
Tobacco Use Cessation Counseling |
2.16.840.1.113883.3.526.3.509 |
| Intervention, Performed |
Tobacco Use Cessation Counseling |
2.16.840.1.113883.3.526.3.509 |
| Medication, Active |
Tobacco Use Cessation Pharmacotherapy |
2.16.840.1.113883.3.526.3.1190 |
| Medication, Not Ordered |
Tobacco Use Cessation Pharmacotherapy |
2.16.840.1.113883.3.526.3.1190 |
| Medication, Order |
Tobacco Use Cessation Pharmacotherapy |
2.16.840.1.113883.3.526.3.1190 |
| Patient Characteristic Ethnicity |
Ethnicity |
2.16.840.1.114222.4.11.837 |
| Patient Characteristic Payer |
Payer |
2.16.840.1.114222.4.11.3591 |
| Patient Characteristic Race |
Race |
2.16.840.1.114222.4.11.836 |
| Patient Characteristic Sex |
ONC Administrative Sex |
2.16.840.1.113762.1.4.1 |
References
CITATIONSiu, A. L.; U.S. Preventive Services Task Force. (2015). Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 163(8), 622-634. doi:10.7326/M15-2023
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].
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 PCPI’s and AMA’s significant past efforts and contributions to the development and updating of the measure are acknowledged. (C) 2012-2020 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) contained in the Measure specifications is copyright 2004-2020 American Medical Association. LOINC(R) copyright 2004-2020 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2020 International Health Terminology Standards Development Organisation. ICD-10 copyright 2020 World Health Organization. All Rights Reserved.
Source:
https://ecqi.healthit.gov/ecqm/measures/cmsv1