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Preventive Care & Screening: Tobacco Use: Screening and Cessation Intervention

Updated: 06/15/2020
Views: 1740

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention 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 within 24 months
  2. Percentage of patients aged 18 years and older who were screened for tobacco use and identified as a tobacco user who received tobacco cessation intervention
  3. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user
Denominator:  Denominator 1:  All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period.
  • Patient’s age is calculated based on the patient’s Date of Birth, which is entered when you created the patient’s account.
Denominator 2:   All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period who were screened for tobacco use and identified as a tobacco user.
  • Patient’s age is calculated based on the patient’s Date of Birth, which is entered when you created the patient’s account.
  • Smoking Status is entered in Social History.
  • Tobacco Use Screening (Age 12+): Tobacco Use Screening Completed is documented under Care Checklist on the date that it was discussed with the patient which should be the date of the note.

Denominator 3:  All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period.

  • Patient’s age is calculated based on the patient’s Date of Birth, which is entered when you created the patient’s account.
Numerator: Numerator 1: Patients who were screened for tobacco use at least once within 24 months.
  • Smoking Status is entered in Social History.
  • Tobacco Use Screening (Age 12+): Tobacco Use Screening Completed is documented under Care Checklist on the date that it was discussed with the patient which should be the date of the note.
Numerator 2: Patients who received a tobacco cessation intervention.
  • Tobacco Cessation Counseling (Age 12+): Cessation counseling provided is documented under Care Checklist on the date that it was discussed with the patient which should be the date of the note.
Numerator 3: Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user.
  • Smoking Status is entered in Social History.
  • Tobacco Use Screening (Age 12+): Tobacco Use Screening Completed is documented under Care Checklist on the date that it was discussed with the patient which should be the date of the note.
  • Tobacco Cessation Counseling (Age 12+): Cessation counseling provided is documented under Care Checklist on the date that it was discussed with the patient which should be the date of the note.
Denominator Exceptions: Exception 1: Any medical reason for not screening for tobacco use
  • Medical Reasons are indicated in the Exception section.
Exception 2: Any medical reason(s) for not providing tobacco cessation intervention
  • Medical Reasons are indicated in the Exception section. 
Exception 3: Any medical reason(s) for not screening for tobacco use OR for not providing tobacco cessation intervention for patients identified as tobacco users
Office Visit Documentation:

Once all steps have been completed, the measure will be added to the Quality Report.

Guidance: If a patient has multiple tobacco use screenings during the 24-month period, only the most recent screening, which has a documented status of tobacco user or tobacco non-user, will be used to satisfy the measure requirements.   
Quality ID: 226
CMS Measure ID: CMS138
Measure type: Process
High Priority Measure: No