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

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Overview

Prime Suite Reporting reports three separate rates for this measure:

• Rate #1: Reports on patients who were screened for tobacco use at least once during the 24 months prior to the measurement period’s end date. To report on rate #1, select 2020 CMS 138 Rate 1 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Screened for Tobacco Use.
• Rate #2. Reports on the percentage of tobacco users who received a tobacco-cessation intervention. To report on rate #2, select 2020 CMS 138 Rate 2 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Cessation Intervention for Tobacco Users.
• Rate #3. Reports on the percentage of patients who were screened for tobacco use one or more times during the 24 months prior to the measurement period end date. Patients who were identified as tobacco users must receive a tobacco-cessation intervention. To report on rate #3, select 2020 CMS 138 Rate 3 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention.

At a Glance

eMeasure ID	CMS138v8
NQF	0028e
Used For?	Medicaid PI/Stage 3, MIPS (Quality)
Domain	Community/Population Health
MIPS Quality ID	226
MIPS Measure Type	Process
MIPS High Priority?	No

Measure Specification and Value Sets

You should be familiar with this measure’s specification, Value Sets, and direct reference codes (if applicable). Refer to Downloading Measure Specifications and Value Sets for more information. Measure help now includes hyperlinks to the Value Sets used by this measure. You must be registered for a UMLS license and signed in to your account to see this content.

Identifying Event Times

See Identifying Event Times for important information about the logic this dashboard uses.

Amending Signed Notes

As a best practice, Notes should not be signed until they are finalized. Amending a signed Note (by making changes to it in Prime Suite and then re-saving it) will change a patient’s qualification for this measure. Re-signing the amended Note may allow the patient to qualify again, but only if it is re-signed during the time period required by the measure.

Documenting Recorded Medications in Prime Mobile

If using Prime Mobile to document a recorded medication, you must enter a non-zero duration. Entering a duration ensures the medication's end date calculates properly and that the medication can qualify for eCQMs. Otherwise, Prime Mobile defaults the medication's end date to midnight of the date recorded. Since this can cause the medication’s end date and time to occur before its start date and time, the medication would not count towards any eCQMs looking for active medications.

Measure Calculations

Initial Population	All patients aged 18 years and older who were seen for at least two visits or at least one preventative visit during the measurement period.
Denominator	Rate #1: Equals Initial Population. Rate #2: Equals Initial Population who were screened for tobacco use and identified as a tobacco user. Rate #3: Equals Initial Population.
Numerator	Rate #1: Patients who were screened for tobacco use at least once within 24 months. Rate #2: Patients who received tobacco cessation intervention. Rate #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 Details

This measure uses tobacco screenings to qualify patients for its criteria. Note the following about documenting these screenings.

Documenting Tobacco Screenings

The patient’s tobacco screening date must be documented in one of the following places: as a vocabulary term in the Results or in a Flowsheet (with a collection/result date) or Social History (SHx). Note that Greenway recommends that you use Flowsheets or Results to record a patient’s tobacco screenings. See Documenting Tobacco Use in Social History for more information.

Documenting Tobacco Use in Results or in a Flowsheet

When documenting the results of a tobacco screening in the Results or a Flowsheet, you must set up a single vocabulary term that contains both a LOINC code for the tobacco screening at the parent level and at least one SNOMED code for the tobacco status at the child level. If the tobacco screening LOINC parent code and the tobacco status SNOMED child code are not both contained in the same vocabulary term, patients will not qualify for this measure.

Documenting Tobacco Use in Social History

When documenting the results of a tobacco screening in Social History, you must select the Substance Use category and then the Tobacco term. Select Details, enter the results of the screening, and then enter the Screening Date. The Screening Date must be entered using the mm/dd/yyyy format.

You must use the Tobacco term shipped with your Prime Suite system to receive credit for this measure. Custom tobacco terms will not qualify.

However, note that Greenway recommends that you use Flowsheets or Results to record a patient’s tobacco screenings. While tobacco screenings documented in Social History can qualify a patient, you need to be aware of the following:

Need for Adding LOINCS

For tobacco screening results documented in Social History to qualify a patient, a LOINC code should be added from the Tobacco Use Screening Value Set. Use the History and Habits Code Mapper to add one of these codes to the term (Chart > Vocabulary Admin > Code Mapper > SHx tab). For Tobacco terms, if a SNOMED code is also listed, you should remove the SNOMED code from the Code Mapper. The term should only have a LOINC code.

Prime Mobile Cannot Be Used to Document a Tobacco Screening in Social History

Tobacco screenings documented in Social History must have a Screening Date to qualify a patient for this measure. Screening Dates cannot be entered in Prime Mobile at this time. You must use Prime Suite when documenting a tobacco screening in Social History.

Resolving Multiple Tobacco-Use Statuses

When multiple tobacco-use statuses are documented, the status with the most recent date will be used.

Initial Patient Population

This criteria is used by all three rates. Patients are counted in the initial patient population if they meet both of the following:

1.

They were 18 years old or older at the start of the measurement period. Age is based on the date of birth (DOB) entered on the patient’s Information page.

2.

They had either one or two non-voided face-to-face encounters during the measurement period. The minimum number of encounters required depends on the type of encounter. These encounters must be documented in either the Plan or E&M section of a Note:

• Patients who had at least one encounter that was documented using a code from one of the following Value Sets can qualify:
  • Annual Wellness Visit
  • Preventive Care Services - Established Office Visit, 18 and Up
  • Preventive Care Services - Group Counseling
  • Preventive Care Services-Individual Counseling
  • Preventive Care Services-Initial Office Visit, 18 and Up
  • Preventive Care Services - Other
• Patients who had two or more encounters that were documented using a code from at least one of the following Value Sets can qualify. Note that these encounters must have been with the same provider:
  • Health & Behavioral Assessment – Individual
  • Health and Behavioral Assessment – Initial
  • Health and Behavioral Assessment, Reassessment
  • Home Healthcare Services
  • Occupational Therapy Evaluation
  • Office Visit
  • Ophthalmological Services
  • Psych Visit - Diagnostic Evaluation
  • Psych Visit - Psychotherapy
  • Psychoanalysis
  • Speech and Hearing Evaluation

Rate #1

Patients are counted in Rate #1 if they meet the following criteria. Select a link for additional information.

Rate #1 Denominator

The denominator for Rate #1 equals the Initial Patient Population.

Rate #1 Denominator Exception

Patients will be removed from the denominator if they do not qualify for the Rate #1 numerator criteria and if they meet either of the following:

• They were diagnosed with limited life expectancy. This diagnosis must not be marked as Resolved before the end of the measurement period. It must be documented using a code from the Limited Life Expectancy Value Set. This can be indicated by either of the following:

• An active diagnosis documented in Past Medical History (PMHx) on the Facesheet. The diagnosis must be documented with a valid onset date. Note that if the diagnosis is entered in Past Medical History (PMHx), the diagnosis will remain in the patient's history indefinitely. The only way to end the diagnosis is to add it through the Problem List and enter a resolved date or inactivate it.
• An active, resolved, or inactive diagnosis in Assessment or the Problem List. The diagnosis must be documented with a valid onset date. If resolved, the diagnosis must also have a valid resolved date.

• They were not screened for tobacco use due to a medical reason. This must be documented as a vocabulary term with a parent code from the Tobacco Use Screening Value Set and a child code from the Medical Reason Value Set. This documentation must be made in the Results or in a Flowsheet during the 24 months prior to the measurement period end date.

Rate #1 Numerator

Patients are counted in this rate’s numerator if they were screened for tobacco use at least once during the 24 months prior to the measurement period’s end date. The results of this screening must be documented either in Social History (SHx) or with a vocabulary term in the Results or in a Flowsheet. Tobacco users will be documented as a current, heavy, or light user of tobacco. Non-tobacco users will be documented to have never used tobacco or that they are a former tobacco user.

See Documenting Tobacco Screenings for additional information.

Rate #2

Patients are counted in Rate #2 if they meet the following criteria:

Rate #2 Denominator

The denominator for Rate #2 equals the Initial Patient Population who were screened for tobacco use and identified as a tobacco user.

Patients who qualified for the Initial Patient Population are counted in the denominator of Rate #2 if they were documented to be a current, heavy, or light user of tobacco during the most recent tobacco screening that occurred during the 24 months prior to the measurement period end date. This must be documented either in Social History (SHx) or with a vocabulary term in the Results or in a Flowsheet during the 24 months prior to the measurement period end date.

See Documenting Tobacco Screenings for additional information.

Rate #2 Denominator Exception

Patients will be removed from the denominator if they do not qualify for the Rate #2 numerator criteria and if they meet either of the following:

• They were diagnosed with limited life expectancy. This diagnosis must not be marked as Resolved before the end of the measurement period. It must be documented using a code from the Limited Life Expectancy Value Set. This can be indicated by either of the following:

• An active diagnosis documented in Past Medical History (PMHx) on the Facesheet. The diagnosis must be documented with a valid onset date. Note that if the diagnosis is entered in Past Medical History (PMHx), the diagnosis will remain in the patient's history indefinitely. The only way to end the diagnosis is to add it through the Problem List and enter a resolved date or inactivate it.
• An active, resolved, or inactive diagnosis in Assessment or the Problem List. The diagnosis must be documented with a valid onset date. If resolved, the diagnosis must also have a valid resolved date.

• They did not receive tobacco-cessation counseling due to a medical reason. This must be documented as a vocabulary term with a parent code from the Tobacco Use Cessation Counseling Value Set and a child code from the Medical Reason Value Set. This documentation must be made in the Results or in a Flowsheet between the date of their most-recent tobacco screening and the end of the measurement period.
• They did not receive tobacco-cessation medication due to a medical reason. This must be documented as a vocabulary term with a parent code from the Tobacco Use Cessation Pharmacotherapy Value Set and a child code from the Medical Reason Value Set. This documentation must be made in the Results or in a Flowsheet between the date of their most-recent tobacco screening and the end of the measurement period.

Rate #2 Numerator

Patients are counted in this rate’s numerator if they received a tobacco-cessation intervention between the date of their most-recent tobacco screening and the end of the measurement period. They must have one of the following:

• Tobacco-cessation counseling. This must be documented using a code from the Tobacco Use Cessation Counseling Value Set. This documentation must appear in one of the following:
  • With a vocabulary term in the Results or in a Flowsheet
  • In Orders Tracking History (with a status of Returned or Reviewed)
• Tobacco-cessation medications. This prescription must meet both of the following:

a.

It was documented using a code from the Tobacco Use Cessation Pharmacotherapy Value Set. This documentation must appear in the Plan section of a Note or on the Medication List.

b.

It was e-prescribed or printed.

If using Prime Mobile to document a recorded medication, you must enter a non-zero duration for the medication to qualify. See Documenting Recorded Medications above for more information.

A tobacco-cessation intervention must occur between the date of the patient’s most recent tobacco screening and the end of the measurement period. For tobacco cessation counseling, if a tobacco user is screened for tobacco use in January, receives tobacco-cessation counseling, and is then screened for tobacco use again in November, they will not qualify for this numerator unless they receive qualifying tobacco-cessation intervention after the November screening date but before the end of the measurement period. However, this does not apply to tobacco-cessation medications. If a patient is prescribed a tobacco-cessation medication by the practice and the medication is still active after the measurement period, they will qualify for the numerator.

Rate #3

Patients are counted in Rate #3 if they meet the following criteria:

Rate #3 Denominator

The denominator for Rate #3 equals the Initial Patient Population.

Population #3 Denominator Exception

Patients will be removed from the denominator of Rate #3 if they do not qualify for the numerator criteria and if they meet any of the following:

• They were diagnosed with limited life expectancy. This diagnosis must not be marked as Resolved before the end of the measurement period. It must be documented using a code from the Limited Life Expectancy Value Set. This can be indicated by either of the following:

• An active diagnosis documented in Past Medical History (PMHx) on the Facesheet. The diagnosis must be documented with a valid onset date. Note that if the diagnosis is entered in Past Medical History (PMHx), the diagnosis will remain in the patient's history indefinitely. The only way to end the diagnosis is to add it through the Problem List and enter a resolved date or inactivate it.
• An active, resolved, or inactive diagnosis in Assessment or the Problem List. The diagnosis must be documented with a valid onset date. If resolved, the diagnosis must also have a valid resolved date.

• They were not screened for tobacco use due to a medical reason. This must be documented as a vocabulary term with a parent code from the Tobacco Use Screening Value Set and a child code from the Medical Reason Value Set. This documentation must be made in the Results or in a Flowsheet during the 24 months prior to the measurement period end date.
• They did not receive tobacco-cessation counseling due to a medical reason. This must be documented as a vocabulary term with a parent code from the Tobacco Use Cessation Counseling Value Set and a child code from the Medical Reason Value Set. This documentation must be made in the Results or in a Flowsheet between the date of their most-recent tobacco screening and the end of the measurement period.
• They did not receive tobacco-cessation medication due to a medical reason. This must be documented as a vocabulary term with a parent code from the Tobacco Use Cessation Pharmacotherapy Value Set and a child code from the Medical Reason Value Set. This documentation must be made in the Results or in a Flowsheet between the date of their most-recent tobacco screening and the end of the measurement period.

Rate #3 Numerator

Patients are counted in this population’s numerator if they meet either of the following sets of criteria. See Documenting Tobacco Screenings for additional information.

Non-Tobacco User Criteria Set

Patients qualify for the Rate #3 numerator under this criteria set if the most recent tobacco screening that occurred during the 24 months prior to the measurement period end date found that they never used tobacco or that they are a former tobacco user. The results of this screening must be documented either in Social History (SHx) or with a vocabulary term in the Results or in a Flowsheet.

Tobacco User Criteria Set

Patients qualify for the Rate #3 numerator under this criteria set if they meet the following:

1.

They were found to be a current, heavy, or light user of tobacco during the most recent tobacco screening that occurred during the 24 months prior to the measurement period end date. The results of this screening must be documented either in Social History (SHx) or in the Results or in a Flowsheet.

2.

They had one of the following between the date of their most-recent tobacco screening and the end of the measurement period:

• Tobacco-cessation counseling. This must be documented using a code from the Tobacco Use Cessation Counseling Value Set. This documentation must appear in one of the following:
  • with a vocabulary term in the Results or in a Flowsheet
  • in Orders Tracking History (with a status of Returned or Reviewed)
• Tobacco-cessation medications. This prescription must meet both of the following:

a.

It was documented using a code from the Tobacco Use Cessation Pharmacotherapy Value Set. This documentation must appear in the Plan section of a Note or on the Medication List.

b.

It was e-prescribed or printed.

If using Prime Mobile to document a recorded medication, you must enter a non-zero duration for the medication to qualify. See Documenting Recorded Medications above for more information.

A tobacco-cessation intervention must occur between the date of the patient’s most recent tobacco screening and the end of the measurement period. For tobacco-cessation counseling, if a tobacco user is screened for tobacco use in January, receives tobacco-cessation counseling, and is then screened for tobacco use again in November, they will not qualify for this numerator unless they receive qualifying tobacco-cessation intervention after the November screening date but before the end of the measurement period. However, this does not apply to tobacco-cessation medications. If a patient is prescribed a tobacco-cessation medication by the practice and the medication is still active after the measurement period, they will qualify for the numerator.

Numerator Exclusions

Not applicable