Thank you for your inquiry regarding CMS138v12 (2024 Performance Period) and CMS138v13 (2025 Performance Period). The response will be in the context of CMS138v13. According to the measure steward, the National Committee for Quality Assurance, a qualifying denominator encounter will be evaluated based on the following measure requirement: at least two visits (see definition 'Qualifying Visit During Measurement Period') or at least one preventive visit (see definition 'Preventive Visit During Measurement Period') during the measurement period. This measure has 3 population criteria so please refer to the measure specifications for each population criteria's requirements: https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS138v13.html . Please note that the logic does not require the tobacco use screenings to be tied to the initial population encounter; when evaluating the tobacco use screening criteria, the measure considers the most recent tobacco use screening taken during the measurement period. Clinically equivalent services may be mapped to the codes used in a measure's value sets to satisfy a value set requirement. The value set description language is used to overall describe the clinical concept. We do not provide prescriptive mapping guidance on the value sets. If mapping is conducted, you should maintain documentation in case of a CMS audit. If you need assistance reviewing data requirements from measure specifications, please refer to guidance available on eCQI Resource Center. Please note that the AIR EC eCQM team coordinates with measure stewards on questions on eCQM specifications and logic, given that measures are owned and maintained by measure stewards. For inquiries about CMS quality program reporting requirements or other quality measure collection types (e.g., MIPS CQM), please review the QPP website or contact the QPP Helpdesk at QPP@cms.hhs.gov .

Clarification of CMS 138_2 mapping values: If a patient has multiple visits within a year, would the smoking status documented during the in-person office visits with the eligible clinician be the only criteria that would be used to determine if the measure would be MET or UNMET for the reporting period? PATIENT EXAMPLE: A patient has 2 office visits in 2024. For both office visits in 2024, the smoking status was documented as NEVER. After the 2 office visits, the patient came in for a PET Scan Procedure and the smoking status was documented as CURRENT during the encounter Which value should be used to determine if the measure is MET or UNMET? • Should both office visits and testing procedure encounters be included in mapping for the measurement period? • To review, ALL OFFICE VISITS were documented as NEVER. Should mapping be to the a) in-person office visit OR the b) testing procedure encounter? It is our understanding that testing procedures are NOT included for the MIPS quality measures as procedures do NOT trigger Quality Measures. Please escalate to a physician at CMS.