Thank you for your inquiry about CMS138v11: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention. To answer your first two questions, numerator 2 requires tobacco cessation interventions received during the measurement period or in the six months prior to the measurement period, therefore, the date/time of “Tobacco Cessation Pharmacotherapy Ordered” and “Active Pharmacotherapy for Tobacco Cessation” should be documented in order to meet the criteria. More details are provided below.
The measure logic definition for “Tobacco Cessation Pharmacotherapy Ordered” requires a “Medication, Order” QDM datatype using a code from the value set “Tobacco Use Cessation Pharmacotherapy” where the “authorDatetime” (date/time the medication order is authored) is within the required timeframe.
Tobacco Cessation Pharmacotherapy Ordered
["Medication, Order": "Tobacco Use Cessation Pharmacotherapy"] CessationPharmacotherapyOrdered
where CessationPharmacotherapyOrdered.authorDatetime during day of Interval[start of "Measurement Period" - 6 months,
end of "Measurement Period"])
The measure logic definition for “Active Pharmacotherapy for Tobacco Cessation” requires a “Medication, Active” QDM datatype using a code from the value set “Tobacco Use Cessation Pharmacotherapy” where the “relevantPeriod” (start/stop time for active medication) and “relevantDatetime” (time the medication is active on the medication record if it was given or taken at a single point in time) is within the required timeframe.
Active Pharmacotherapy for Tobacco Cessation
["Medication, Active": "Tobacco Use Cessation Pharmacotherapy"] TakingCessationPharmacotherapy
where Global."NormalizeInterval" ( TakingCessationPharmacotherapy.relevantDatetime, TakingCessationPharmacotherapy.relevantPeriod ) during day of Interval[start of "Measurement Period" - 6 months,
end of "Measurement Period"]
To answer your third question, eligible tobacco use cessation pharmacotherapy codes are those defined by the codes listed in the value set "Tobacco Use Cessation Pharmacotherapy" (OID: 2.16.840.1.113883.3.526.3.1190). For more guidance on viewing codes from the value sets and how to read an eCQM in general, please refer to this guidance available on the eCQI Resource Center:
https://ecqi.healthit.gov/sites/default/files/Guide-for-Reading-eCQMs-v8.pdf.
EH/CAH eCQMs
Moderate