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  2. CQM-6096

CMS 138 v11 Tobacco Use Status

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    • Resolution: Answered
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      Thank you for your inquiry about CMS138v11. This measure is based on the US Preventive Services Task Force (USPSTF) which recommends that adults that use any type of tobacco product receive cessation intervention: either counseling and or pharmacotherapy. Patients that smoke or use smokeless tobacco should be screened for tobacco use. To meet the tobacco use screening criteria, this measure requires a QDM datatype "Assessment, Performed" along with the value set "Tobacco Use Screening" ( https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.526.3.1278/expansion/eCQM%20Update%202022-05-05 ), and requires a result using the QDM attribute "result". The "result" attribute must be identified as either "Tobacco Non-User" ( https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.526.3.1189/expansion/eCQM%20Update%202022-05-05 ) or "Tobacco User" ( https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.526.3.1170/expansion/eCQM%20Update%202022-05-05 ). The information mentioned above should be documented in structured fields in EHR. If the terminology is not natively supported by your EHR, you may map clinically equivalent services to the codes contained in the above mentioned value sets. Please note, if mapping does occur, you should maintain documentation in case of a CMS audit.

      This measure contains three different reporting rates. The first rate identifies patients who were screened for tobacco use. The second rate assesses whether patients who were identified as tobacco users received a tobacco cessation intervention. The third rate is a comprehensive look at the overall performance on tobacco screening and cessation intervention and assesses whether patients received screening for tobacco use, and if found to be tobacco users, received a tobacco cessation intervention. As per the CQL, the logic will take in the most recent screening performed which would be March 1 according to your example. Therefore, the patient would meet Numerator 1 and Numerator 3 criteria.
      Show
      Thank you for your inquiry about CMS138v11. This measure is based on the US Preventive Services Task Force (USPSTF) which recommends that adults that use any type of tobacco product receive cessation intervention: either counseling and or pharmacotherapy. Patients that smoke or use smokeless tobacco should be screened for tobacco use. To meet the tobacco use screening criteria, this measure requires a QDM datatype "Assessment, Performed" along with the value set "Tobacco Use Screening" ( https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.526.3.1278/expansion/eCQM%20Update%202022-05-05 ), and requires a result using the QDM attribute "result". The "result" attribute must be identified as either "Tobacco Non-User" ( https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.526.3.1189/expansion/eCQM%20Update%202022-05-05 ) or "Tobacco User" ( https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.526.3.1170/expansion/eCQM%20Update%202022-05-05 ). The information mentioned above should be documented in structured fields in EHR. If the terminology is not natively supported by your EHR, you may map clinically equivalent services to the codes contained in the above mentioned value sets. Please note, if mapping does occur, you should maintain documentation in case of a CMS audit. This measure contains three different reporting rates. The first rate identifies patients who were screened for tobacco use. The second rate assesses whether patients who were identified as tobacco users received a tobacco cessation intervention. The third rate is a comprehensive look at the overall performance on tobacco screening and cessation intervention and assesses whether patients received screening for tobacco use, and if found to be tobacco users, received a tobacco cessation intervention. As per the CQL, the logic will take in the most recent screening performed which would be March 1 according to your example. Therefore, the patient would meet Numerator 1 and Numerator 3 criteria.
    • CMS0138v12
    • CMS0138v11
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      For accurate reporting , we are asking for clarification of numerator requirements.
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      For accurate reporting , we are asking for clarification of numerator requirements.

      The intent of the measure is to screen patients for the use of all forms of tobacco. New for v 11 is that e-cigarettes are now included  in the definition of tobacco use. 

      Now that eCigarettes are to be included, to meet numerator requirements, does the medical record have to show that separate questions are asked regarding all 3 of 

      • Smoking status
      • Smokeless tobacco use status
      • e-Cigarette use status?

      Or is screening for only one type of tobacco use sufficient?

      Example:

      January 15 - Smoking status Positive/Smokeless tobacco use- Negative

      March 1 - Smokeless tobacco use - Negative

      Since the most recent screen is negative, but only included a response regarding smokeless tobacco, would numerator requirements be met, even though no intervention occurred regarding the smoking reported on January 15?

            edave Mathematica EC eCQM Team
            hensonsw@bcm.edu Gail Henson-Swaney
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