eCQM 226 numerator question

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • Renee Freyer
    • 865-643-8206
    • Verana Health, MIPS Registry
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      Thank you for your inquiry about CMS138v13 (performance period 2025). The measure identifies 3 populations. Numerator 1 looks for screening completed. Numerator 2 and Numerator 3 look for tobacco cessation interventions if the screening is positive. One way of meeting tobacco cessation intervention is through documentation of an "Intervention, Performed" using any codes from the value set "Tobacco Use Cessation Counseling" (2.16.840.1.113883.3.526.3.509). The intent is that education be provided via two-way interaction between the patient and provider. 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 about understanding measure requirements, you may refer to the "Guide for Reading eCQMs" for additional guidance. 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 CMS138v13 (performance period 2025). The measure identifies 3 populations. Numerator 1 looks for screening completed. Numerator 2 and Numerator 3 look for tobacco cessation interventions if the screening is positive. One way of meeting tobacco cessation intervention is through documentation of an "Intervention, Performed" using any codes from the value set "Tobacco Use Cessation Counseling" (2.16.840.1.113883.3.526.3.509). The intent is that education be provided via two-way interaction between the patient and provider. 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 about understanding measure requirements, you may refer to the "Guide for Reading eCQMs" for additional guidance. 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
    • Numerator scoring impact

      Question about Strata 2 for eCQM 226 Tobacco Cessation measure: - A practice wants to improve their Strata 2 score and also for overall clinical compliance auditing. They would like to contact unfavorable patients, speak to them verbally and provide brief cessation counseling. When done, they would ideally like to select a checkbox in the EHR that they did provide cessation counseling and would add a brief chart note stating that they provided verbal counseling in 2025. Question: If they complete the above, can the practice receive numerator credit in regards to meeting the measure's intent and pass a Quality audit? They WILL be favorable in the registry based on the EHR selections but we need to confirm that this measure does in fact allow it.

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Renee Freyer
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