eCQM: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (CMS 138v5)

eCQM:

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

CMS ID:

CMS 138v5

Measure Type:

Process

Quality ID:

226

MIPS High Priority Measure:

No

Eligible for Quality Programs:

  • Merit-Based Incentive Payment System (MIPS)
  • Medicaid EHR Incentive Program (Meaningful Use)
  • Comprehensive Primary Care Plus (CPC+)

Performance Benchmark for MIPS:

98.52%

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.

  • Numerator: Patients who were screened for tobacco use at least once within 24 months before the end of the measurement period AND who received tobacco cessation intervention if identified as a tobacco user.

  • Denominator: All patients aged 18 years and older seen for at least one preventive visit (defined as a chart note with one of the following encounter types: Office Visit, Home Visit, Nurse Visit, or Nursing Home Visit) during the measurement period.

    • Denominator Exclusions: None

    • Denominator Exceptions: Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reason).

eCQM Patient Reports

eCQM Patient Reports can help you identify patient care gaps and improve the performance of your quality measures. Click on the blue result numbers in the eCQM Dashboard to see the patient report for this measure.

The eCQM Patient Reports list the individual patients included in the measure’s population, which measure cohorts the patient is in, and contact information for the patient to streamline any downstream communication that may be needed to fulfill the measure requirements. You can choose to print the patient list for a measure or export it as a CSV.

The measure cohorts included in the eCQM Patient Report for CMS 138v5 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention are:

  • Initial patient population
  • Denominator
  • Numerator
  • Exception

Practice Fusion Suggested Workflow
Practice Fusion suggests the following workflow to help ensure that you are able to meet the requirements of this measure within the Practice Fusion EHR.

  1. Ensure that all patients age 18 and older have a smoking status recorded in the Social History section of his or her chart at least once within the 24 months before the end of the current measurement period.
  2. Review the status to determine whether the patient is identified as a tobacco user. The smoking statuses used to identify if a patient is a tobacco user are indicated in Table 1.
  3. If the patient’s smoking status indicates they are a tobacco user, document a tobacco cessation intervention using the suggested workflows detailed in Table 2.

Table 1: Smoking Statuses to Determine Tobacco Users

Smoking Status

Action Required

  • Never smoker
  • Former smoker
  • None

  • Current everyday smoker
  • Current some day smoker
  • Smoker, current status unknown
  • Heavy tobacco smoker
  • Light tobacco smoker
  • Tobacco cessation counseling intervention

Table 2: Practice Fusion Suggested Workflows for Tobacco Cessation Interventions

Intervention Type

Practice Fusion Suggested Workflows

Tobacco Cessation

  • In the Screenings/Interventions/Assessments section of the encounter, search for tobacco cessation counseling and select the applicable item. Examples include:

    • Smoking cessation education (procedure) (SNOMED CT 225323000)

    • Referral to stop smoking clinic (procedure) (SNOMED CT 315232003)

    • Smoking effects education (procedure) (SNOMED CT 225324006)

  • Record and save the following information in the modal window that opens:

    • Status: Performed

    • Start Date: If the procedure was performed on the same date of service as the encounter in which it is recorded in the Screenings/Interventions/Assessments section, a start or end date should not be entered for the procedure. (See Graphic 1 for example.) 

OR

  • In the Medications or Plan section of the patient encounter, complete an order for appropriate tobacco use cessation medication therapy. Examples include:

    • Topiramate 50 MG Oral Tablet (RXNORM 151226)

    • Nortriptyline 10 MG Oral Capsule (RXNORM 198045)

    • 24 HR Nicotine 0.292 MG/HR Transdermal Patch (RXNORM 198031)

Note: if the patient already has an active instance (i.e. no stop date) of an appropriate tobacco use cessation medication already recorded in their chart, this will also count towards the measure numerator.

Graphic 1: Example of data elements for recording Screenings/Interventions/Assessments

To access a complete list of appropriate tobacco use cessation medication therapy, visit the United States Health Information Knowledgebase (USHIK). This site is produced by the Agency for Healthcare Research and Quality (AHRQ) in partnership with CMS and the National Library of Medicine (NLM). A free Unified Medical Language System® (UMLS) license, available from NLM, is required to access USHIK.

Additional Measure Information

  • This 2016 measure version has been updated from the previous 2015 version specifications, incorporating the following change:

    • Added guidance regarding the omission of electronic nicotine delivery systems (ENDS) from this measure due to insufficient evidence.

    • Updated guidance related to denominator exception applicability; clarified the medical reason exception is unchanged, but the limited life expectancy applicability has been updated.

    • Expanded the applicability of the “Limited Life Expectancy” denominator exception to apply to either of the numerator quality actions (screening or cessation intervention). If a patient has a diagnosis of “Limited Life Expectancy,” it is an allowable exception.

    • Added “Home Healthcare Services” as applicable encounters.

  • To be recognized for the denominator exception, the patient must have the appropriate medical reason recorded in his or her chart, as detailed in the suggested workflow in Table 3 below.

  • To access a complete list of applicable tobacco use screenings, visit the United States Health Information Knowledgebase (USHIK).

  • For the purposes of this measure, “Tobacco Use” includes any type of tobacco and “Tobacco Cessation Intervention” includes brief counseling (3 minutes or less) and/or pharmacotherapy. 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.

Table 3. Practice Fusion Suggested Workflow for CMS 138v5 Denominator Exceptions

Denominator Exception Criteria

Practice Fusion Suggested Workflow

Medical Reason not done

  • In the Screenings/Interventions/Assessments section of the encounter, search for the applicable tobacco use screening and select the item. Examples include:

    • Have you used tobacco in the last 30 days SAMHSA (LOINC 68535-4)

    • Have you used smokeless tobacco product in the last 30 days SAMHSA (LOINC 68536-2)

  • Record and save the following information in the modal window that opens:

    • Status: Not Performed

    • Reason: Medical contraindication, Procedure contraindicated, OR Treatment not tolerated

    • Start Date: If the screening refusal was made on the same date of service as the encounter in which it is recorded in the Screenings/Interventions/Assessments section, a start or end date should not be entered for the screening refusal. 

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