2025 - CMS138 Tobacco Cessation after billable event

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • Molly Minehan
    • 6036676996
    • OneGI
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      Thank you for your inquiry about CMS138v12 (performance period 2024). The measure identifies 3 populations. Numerator 1 looks for documentation of tobacco use screening. Numerator 2 and Numerator 3 look for documentation of tobacco cessation interventions for patients who screen positive.

      One way to meet the tobacco cessation intervention requirement is by documenting an "Intervention, Performed" in the EHR using structured data fields and any code from the value set "Tobacco Use Cessation Counseling" (2.16.840.1.113883.3.526.3.509). In your example, the patient had two qualifying encounters, was identified as a tobacco user during one, and received a cessation intervention during a follow-up phone call. If this intervention is documented accordingly and occurs within the measurement period or the six months prior, it would meet the criteria for Numerator 2 or 3.

      If you have questions regarding implementing the measure, you may refer to the "Implementation Checklist for eCQM Annual Update" for additional guidance. These resources can be found in the eCQI Resource Center: https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=ecqm-resources&global_measure_group=eCQMs.
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      Thank you for your inquiry about CMS138v12 (performance period 2024). The measure identifies 3 populations. Numerator 1 looks for documentation of tobacco use screening. Numerator 2 and Numerator 3 look for documentation of tobacco cessation interventions for patients who screen positive. One way to meet the tobacco cessation intervention requirement is by documenting an "Intervention, Performed" in the EHR using structured data fields and any code from the value set "Tobacco Use Cessation Counseling" (2.16.840.1.113883.3.526.3.509). In your example, the patient had two qualifying encounters, was identified as a tobacco user during one, and received a cessation intervention during a follow-up phone call. If this intervention is documented accordingly and occurs within the measurement period or the six months prior, it would meet the criteria for Numerator 2 or 3. If you have questions regarding implementing the measure, you may refer to the "Implementation Checklist for eCQM Annual Update" for additional guidance. These resources can be found in the eCQI Resource Center: https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=ecqm-resources&global_measure_group=eCQMs .
    • CMS0138v13
    • Practices should have the opportunity to get credit for clinical actions that take place after the time of the visit for the measures, which allow for this. Example is Tobacco Cessation.

      My question pertains to CMS138v12. Suppose a patient has two qualifying encounters, making them eligible for the Tobacco Use: Screening and Cessation Intervention measure. During one of these encounters, the patient is screened and identified as a tobacco user, but the provider does not deliver tobacco cessation counseling during the visit.

      If, after the encounter, the patient is contacted by phone, screened again, and provided with cessation resources (e.g., the tobacco quitline), and this intervention is subsequently documented in the EHR—either through a non-visit note or a telephone visit entry—would this satisfy the criteria for meeting the measure?

      It is my understanding that the cessation counseling does not need to occur during the billable encounter itself. Rather, the critical factor is that the cessation intervention is provided and appropriately documented in the EHR within the measurement period. Could you please confirm whether this approach would qualify the patient as "Met" for the measure?

       

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Molly Minehan
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