CMS138 Tobacco abuse counseling ordered but declined

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
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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). In your example, if a patient had the appropriate visit requirement and was screened for tobacco use at least once during the measurement period, they would meet numerator 1 criteria.

      If you have questions about reading the measure specification or understanding data 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). In your example, if a patient had the appropriate visit requirement and was screened for tobacco use at least once during the measurement period, they would meet numerator 1 criteria. If you have questions about reading the measure specification or understanding data 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
    • could falsely inflate outcomes

      The scenario presented was:

      We have a scenarion for CMS138 where a patient had the appropriate visit and screening, but the provider used a code from the Tobacco abuse counseling value set and attached a qualifier of Patient Declined to it. Does this provider still get credit for attempting to order the counseling and patient meets the Numerator, OR should this patient be counted as NOT meeting the Numerator since no follow up occurred?

       

      The Reply was: 

      he current measure does not include patient reasons for declining tobacco cessation intervention as it does not meet the clinical intent of the measure. We are unable to provide guidance on how these events should be documented in the EHR. We recommend you consult with your EHR vendor and clinical partners. Clinically equivalent services can be mapped to the codes; if mapping is done, you should maintain documentation in case of a CMS audit.

       

      Follow up question: 

      Am I correct in my understanding then, that if a patient declines the tobacco cessation intervention, then the patient would not meet numerator 2 and 3?

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Joseph Long
            Votes:
            2 Vote for this issue
            Watchers:
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              Created:
              Updated:
              Resolved:
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