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  2. CQM-7125

Clarification on scoring for CMS eCQM 138v12

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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    • None
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    • Debbie Young
    • 314-705-5152
    • Signature Medical Group
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      Thank you for your inquiry about CMS138v12 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention. As specified in the Guidance section, "This measure contains three reporting rates which aim to identify patients who were screened for tobacco use (rate/population 1), patients who were identified as tobacco users and who received a tobacco cessation intervention (rate/population 2), and a comprehensive look at the overall performance on tobacco screening and cessation intervention (rate/population 3). By separating this measure into various reporting rates, the eligible clinician will be able to better ascertain where gaps in performance exist, and identify opportunities for improvement. The overall rate (rate/population 3) can be utilized to compare performance to published versions of this measure prior to the 2018 performance year, when the measure had a single performance rate. For accountability reporting in the CMS MIPS program, the rate for population 2 is used for performance." For further questions regarding CMS quality program reporting requirements, you may submit questions to the QPP helpdesk at QPP@cms.hhs.gov or open a service center ticket at https://cmsqualitysupport.servicenowservices.com/ccsq_support_central. We hope this helps.
      Show
      Thank you for your inquiry about CMS138v12 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention. As specified in the Guidance section, "This measure contains three reporting rates which aim to identify patients who were screened for tobacco use (rate/population 1), patients who were identified as tobacco users and who received a tobacco cessation intervention (rate/population 2), and a comprehensive look at the overall performance on tobacco screening and cessation intervention (rate/population 3). By separating this measure into various reporting rates, the eligible clinician will be able to better ascertain where gaps in performance exist, and identify opportunities for improvement. The overall rate (rate/population 3) can be utilized to compare performance to published versions of this measure prior to the 2018 performance year, when the measure had a single performance rate. For accountability reporting in the CMS MIPS program, the rate for population 2 is used for performance." For further questions regarding CMS quality program reporting requirements, you may submit questions to the QPP helpdesk at QPP@cms.hhs.gov or open a service center ticket at https://cmsqualitysupport.servicenowservices.com/ccsq_support_central . We hope this helps.
    • CMS0138v12
    • Trying to determine which stratum denominator qualifies a provider for being able to report a measure? We understand that we would also be subject to the 75% data completeness requirements.

      We have a physician who has 50 patients in the denominator of stratum #1 and he has screened all 50 for a 100% performance to date.  Only 1 of those patients was a tobacco user in stratum #2 of which he provided cessation counseling for a 100% performance.  Would he meet the measure minimum for reporting since he had more than 20 in the denominator of stratum #1 OR would he have to have at least 20 in the denominator of stratum #2, since this is the stratum that the decile scoring is based on for the 2024 reporting year?

            edave Mathematica EC eCQM Team
            dmyoung@signaturehealth.net Debbie Young (Inactive)
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