CMS 138 - Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Overview

CMS138v8 (2020)
CMS138v9 (2021)
CMS138v10 (2022)

Identifiers

CMS eCQM IDNQF eCQM IDNQFMIPS Quality ID
CMS138v100028e0028226
*MIE only supports data collection and reporting using eCQM specifications

Definitions

DescriptionPercentage 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 periodPercentage of patients aged 18 years and older who were identified as a tobacco user who received tobacco cessation interventionPercentage 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
Initial Patient PopulationAll patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period
DenominatorEquals Initial PopulationEquals Initial Population who were screened for tobacco use and identified as a tobacco userEquals Initial Population
Denominator Exclusions
NumeratorPatients who were screened for tobacco use at least once during the measurement periodPatients who received tobacco cessation interventionPatients 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
Numerator Exclusions
Denominator ExceptionsDocumentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reason)Documentation of medical reason(s) for not providing tobacco cessation intervention (e.g., limited life expectancy, other medical reason)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)

Additional Information

Measure TypeProcess measure
Measure ScoringProportion measure
GranularityPatient
Improvement NotationHigher score indicates better quality
DomainCommunity/Population Health

Clinical Instructions

New UI Visit Encounter (valid RC202109+)

Original Visit Encounter

Using the Social History section of the encounter, ensure smoking status is documented and additional details are noted with the respective status (i.e., current smoker, former smoker, etc.). Cessation counseling or medications should be noted, when applicable, in order to populate the numerator appropriately.

  1. While documenting the Visit Encounter, open the Social History section.
  2. Assess Smoking Status: (select one)
    1. Current every day smoker
    2. Current some day smoker
    3. Former smoker
    4. Never smoker
    5. Heavy tobacco smoker
    6. Light tobacco smoker
    7. Smoker, current status unknown
    8. Unknown if ever smoked
  3. Based on the selected smoking status, additional fields/choices may need addressed (e.g., Age Started, Age Quit, Cessation Counseling, etc.). Answer accordingly.
Note
When marking the radio button for Cessation Counseling, the date MUST be entered as well. Selecting only the radio button or providing only a date of counseling will not satisfy the measure.
   2. Continue documenting the encounter as appropriate 3. When complete, Close and Archive the encounter

Evidence

Initial Patient Population

NameValue Set
Encounter, Performed: Annual Wellness Visit2.16.840.1.113883.3.526.3.1240
Encounter, Performed: Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making)CPT Code 96156
Encounter, Performed: Health behavior intervention, individual, face-to-face; initial 30 minutes2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed: Occupational Therapy Evaluation2.16.840.1.113883.3.526.3.1011
Encounter, Performed: Office Visit2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed: Online Assessments2.16.840.1.113883.3.464.1003.101.12.1089
Encounter, Performed: Ophthalmological Services2.16.840.1.113883.3.526.3.1285
Encounter, Performed: Physical Therapy Evaluation2.16.840.1.113883.3.526.3.1022
Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up2.16.840.1.113883.3.464.1003.101.12.1025
Encounter, Performed: Preventive Care Services - Group Counseling2.16.840.1.113883.3.464.1003.101.12.1027
Encounter, Performed: Preventive Care Services - Other2.16.840.1.113883.3.464.1003.101.12.1030
Encounter, Performed: Preventive Care Services-Individual Counseling2.16.840.1.113883.3.464.1003.101.12.1026
Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up2.16.840.1.113883.3.464.1003.101.12.1023
Encounter, Performed: Psych Visit - Diagnostic Evaluation2.16.840.1.113883.3.526.3.1492
Encounter, Performed: Psych Visit - Psychotherapy2.16.840.1.113883.3.526.3.1496
Encounter, Performed: Psychoanalysis2.16.840.1.113883.3.526.3.1141
Encounter, Performed: Speech and Hearing Evaluation2.16.840.1.113883.3.526.3.1530
Encounter, Performed: Telephone Visits2.16.840.1.113883.3.464.1003.101.12.1080

Denominator

NameValue Set
Assessment, Performed: Tobacco Use Screening2.16.840.1.113883.3.526.3.1278

Numerator

NameValue Set
Intervention, Performed: Tobacco Use Cessation Counseling2.16.840.1.113883.3.526.3.509
Medication, Active: Tobacco Use Cessation Pharmacotherapy2.16.840.1.113883.3.526.3.1190
Medication, Order: Tobacco Use Cessation Pharmacotherapy2.16.840.1.113883.3.526.3.1190

Denominator Exceptions

NameValue Set
Assessment, Not Performed: Tobacco Use Screening2.16.840.1.113883.3.526.3.1278
Diagnosis: Limited Life Expectancy2.16.840.1.113883.3.526.3.1259

Source(s)

Medical Codify


WebChart Documentation

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