CMS138v13: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user.

Three rates are reported:

1. Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period
2. Percentage of patients aged 12 years and older who were identified as a tobacco user during the measurement period who received tobacco cessation intervention during the measurement period or 6 months prior to the measurement period
3. Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention during the measurement period or 6 months prior to the measurement period if identified as a tobacco user

Numerator

Patients in the denominator will be included in the numerator if they either weren't tobacco users or were and received a cessation intervention. They must meet Scenario 1 or Scenario 2

Note: Those who are not screened (either no status is selected or the status of "Unknown if ever smoked" is selected) will not qualify for the numerator.

• Screened for tobacco use within the measurement period and were found to not be tobacco users. The patient will count as a non-user (and be counted in the numerator) if either of the following is true:
  • The have a Smoking Status of "Never smoker" or "Former smoker"
  • They do not have an Additional Tobacco Use status of "Yes" for Chewing Tobacco and Pipe Smoker

• Screened for tobacco use within the measurement period and are tobacco users and received a tobacco cessation intervention at least once within the measurement period. The patient must be both screened and have a tobacco cessation intervention done to qualify
  • Tobacco Screening: The patient will count as a tobacco user if:
    • Their smoking status or tobacco use status are any of the following: "Current every day smoker" or "Current some day smoker" or "Smoker, current status unknown" or "Heavy tobacco smoker" or "Light tobacco smoker"
    • If they have an Additional Tobacco Use status of "Yes" for Chewing Tobacco or Pipe Smoker
  • Tobacco Cessation Intervention: There are several ways tobacco cessation interventions can be recorded. Any of the following options below will count as an intervention:
    • Clinical Decision Support: A user completes any of the following Clinical Decision Support rules within the measurement period:
      • Tobacco Smoking Cessation in Pregnant Women
      • Tobacco use counseling and interventions: non-pregnant adults
      • Counseling to Prevent Tobacco Use and Tobacco-Caused Disease in Children or Adolescents
    • Text in Chart: A clinician can record any of the following phrases in the Assessment or Plan sections of the Most Recent Encounter at any time over the measurement period: 
      • Smoking cessation
      • Tobacco cessation
      • quit smoking
      • stop smoking
      • quit tobacco
      • stop tobacco
      • quit using tobacco
      • stop using tobacco
      • quitting smoking
      • stopping smoking
      • quitting tobacco
      • stopping tobacco
      • quitting using tobacco
      • stopping using tobacco
    • Medication: A clinician will have prescribed a qualified tobacco cessation medications for the patient at any time during the measurement period.

Denominator

Population 1

All patients aged 12 years and older seen for at least two visits or at least one preventive visit during the measurement period

Population 2

All patients aged 12 years and older seen for at least two visits or at least one preventive visit during the measurement period and identified as a tobacco user during the measurement period

Population 3

All patients aged 12 years and older seen for at least two visits or at least one preventive visit during the measurement period

Denominator Exclusions

• Exclude patients whose hospice or palliative care overlaps the measurement period:
  • Identified in the patient's Alerts and Directives, located in the demographic screen or the Summary Sheet, in the name, text or comments saved with that alert/directive. The Alert/Directive should include either of the following phrases:
    • palliative
    • hospice