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Clinical Quality Measures

CMS138 - Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

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:

  1. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months
  2. 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
  3. 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

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

Denominator 1: All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period

Numerator 1: Patients who were screened for tobacco use at least once within 24 months

Denominator 2: All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period who were screened for tobacco use and identified as a tobacco user

Numerator 2: Patients who received tobacco cessation intervention

Denominator 3: All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period

Numerator 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

Measure Calculation in ChARM EHR: MANUAL

This measure is calculated based on the assessments and interventions recorded under 'Encounter > MU' section.

To satisfy this measure, for patient with Age >= 18 years, tobacco use screening assessment needs to be performed. If the patient is identified as a tobacco user, tobacco use cessation counseling needs to be provided. All these actions need to be recorded under 'Encounter > MU' section.
Tobacco Use

Denominator Exception: Patients will be automatically exempted if Patient has Diagnosis ‘Limited Life Expectancy’ (Sample SNOMED codes : 162607003, 170969009, 300936002)

You can manually exempt a patient from denominator, based on other conditions listed below under 'Encounter > MU' section.
Tobacco Use Exception