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CMS138v12 multiRate Calculation

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      Thank you for your question regarding CMS138v12 (2024 Performance Period) and CMS138v13 (2025 Performance Period). It is correct that rate/population 3 looks for tobacco cessation interventions if the screening is positive, essentially a combination of the criteria for rate/population 1 and rate/population 2. As specified in the guidance section of the header, "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." You may review the measure specification for further details about measure requirements: https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS138v13.html. For further questions regarding CMS quality program reporting requirements, you may submit questions to the QPP helpdesk at QPP@cms.hhs.gov.
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      Thank you for your question regarding CMS138v12 (2024 Performance Period) and CMS138v13 (2025 Performance Period). It is correct that rate/population 3 looks for tobacco cessation interventions if the screening is positive, essentially a combination of the criteria for rate/population 1 and rate/population 2. As specified in the guidance section of the header, "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." You may review the measure specification for further details about measure requirements: https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS138v13.html . For further questions regarding CMS quality program reporting requirements, you may submit questions to the QPP helpdesk at QPP@cms.hhs.gov .
    • CMS0138v13
    • CMS0138v12

      Question: Is this a right statement? If patients meet both rate 1 and rate 2, then to count as rate 3 they would have to have cessation?{}

      Rate 1: Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period.
      Rate 2: Percentage of patients aged 12 years and older who were identified as a tobacco user during the measurement period who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period.
      Rate 3: Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user.

       

       

            AIR EC eCQM Team AIR EC eCQM Team
            reenaganeshCencora Reena Ganesh
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