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CMS 138 - Preventive Care & Screening: Tobacco Use: Screening and Cessation Intervention

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Updated: 06/13/2023 | Views: 2889

CMS 138 / Quality ID #226

Percentage of patients aged 18 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.

Three rates are reported:

  1. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times during the measurement period.
  2. Percentage of patients aged 18 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.
  3. Percentage of patients aged 18 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.
Denominator:  All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period.

Denominator 1:  Initial population.
  • Patient’s age is calculated based on the patient’s Date of Birth, which was entered when you created the patient’s account.
  • Create a note detailing the patient’s office visit.
Denominator 2: Initial population who were screened for tobacco use during the measurement period and identified as a tobacco user.
  • Patient’s age is calculated based on the patient’s Date of Birth, which was entered when you created the patient’s account.
  • Create a note detailing the patient’s office visit.
  • Smoking Status is entered in Social History.
  • On the date of service, click on Care Checklist from within the note.
  • Select "Completed" for Tobacco Use Screening (Age 12+): Tobacco Use Screening Completed on the date that it was discussed with the patient which should be the date of the note.

Denominator 3:  Initial population.

  • Patient’s age is calculated based on the patient’s Date of Birth, which was entered when you created the patient’s account.
  • Create a note detailing the patient’s office visit.
Denominator Exclusions: Exclude patients who are in hospice care for any part of the measurement period.
  • Hospice is documented under Hospice in History. These patients will be excluded from the denominator.
Numerator: Population 1: Patients who were screened for tobacco use at least once during the measurement period.

Population 2: Patients who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period.

Population 3: Patients who were screened for tobacco use at least once 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.
Office Visit Documentation:

Once all steps have been completed, the measure will be added to the Quality Measures Report.
Measure type: Process
High Priority Measure: No
Telehealth Eligible: Yes