CMS 138v13 Population 2 numerator - Active Medication relevant period

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
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      Thank you for your inquiry regarding CMS138v13 for the 2025 performance period. This measure includes three distinct populations:
      • Numerator 1: Identifies patients who completed a tobacco use screening.
      • Numerators 2 and 3: Identifies tobacco cessation interventions for patients with a positive screening result.

      The resource “Medication, Active” uses the attribute “relevantPeriod”, which captures both the start and end of a medication or intervention timeframe. The measure also uses “relevantDatetime” to indicate a specific point in time when the medication is active or the intervention is performed. To satisfy the numerator requirement, either the “relevantDatetime” or both the start and end of the “relevantPeriod” must fall within the required measurement window. In your example, if the end date is missing from “relevantPeriod”, the patient will not meet the numerator criteria. We will consider updates in a future iteration of the measure.

      If you have questions about understanding measure requirements, you may refer to the "Guide for Reading eCQMs" for additional guidance. This resource 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 regarding CMS138v13 for the 2025 performance period. This measure includes three distinct populations: • Numerator 1: Identifies patients who completed a tobacco use screening. • Numerators 2 and 3: Identifies tobacco cessation interventions for patients with a positive screening result. The resource “Medication, Active” uses the attribute “relevantPeriod”, which captures both the start and end of a medication or intervention timeframe. The measure also uses “relevantDatetime” to indicate a specific point in time when the medication is active or the intervention is performed. To satisfy the numerator requirement, either the “relevantDatetime” or both the start and end of the “relevantPeriod” must fall within the required measurement window. In your example, if the end date is missing from “relevantPeriod”, the patient will not meet the numerator criteria. We will consider updates in a future iteration of the measure. If you have questions about understanding measure requirements, you may refer to the "Guide for Reading eCQMs" for additional guidance. This resource can be found in the eCQI Resource Center: https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=ecqm-resources&global_measure_group=eCQMs .
    • CMS0138v13

      We're having some issues with the "during" operator in the Active Pharmacotherapy criteria for CMS138 numerator 2:

      A client is reporting a patient that meets the denominator and is currently actively on tobacco cessation medication. Thus they are reporting the relevantPeriod for the Medication Active data element with a null end date; this is standard practice when a medication's active period is ongoing. But this is causing the patient to miss the numerator for population 2 since the null end date is considered outside the measurement period.

      Is this expected? This seems odd as I would think a patient who has been screened positive for tobacco use but is actively taking medication would meet the numerator. It seems like the use of "during" would force the need for an end date on the active medication in order to meet that criteria. What is the clinical intent?

        1. image-2025-07-17-10-44-35-876.png
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          Jessica Ordoyne

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Jessica Ordoyne
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