Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (2022)
| eCQMs / NQF #: | CMS138v10 / 0028e |
| Measure: | 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 if identified as a tobacco user
Three rates are reported: a. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times during the measurement period. b. Percentage of patients aged 18 years and older who were identified as a tobacco user who received tobacco cessation intervention. c. 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 if identified as a tobacco user. |
| Numerator: | Population 1: Patients who were screened for tobacco use at least once within 12 months.
Population 2: Patients who received tobacco cessation intervention. Population 3: Patients who were screened for tobacco use at least once within 12 months AND who received tobacco cessation intervention if identified as a tobacco user. |
| Denominator: | Population 1: All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period.
Population 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. Population 3: All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period. |
| Denominator Exceptions: | Population 1: Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reason).
Population 2: Documentation of medical reason(s) for not providing tobacco cessation intervention (e.g., limited life expectancy, other medical reason). Population 3: Documentation of medical reason(s) for not screening for tobacco use OR for not providing tobacco cessation intervention for patients identified as tobacco users (e.g., limited life expectancy, other medical reason). |
| Domain: | Community/Population Health |
In ChartMaker Clinical:
In order to qualify for this measure, the provider must have seen the patient, who is at least 18 years old, for at least 2 visits OR at least 1 preventive visit during the reporting period and have the appropriate information documented in the chart:
Required Data Elements for the Denominator:
At least one of the following:
This is captured by adding a procedure with a valid CPT or SNOMED code using the Procedure widget in a note.
| CPT: | |
| Code | Description |
| 99385 | Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years |
| 99386 | Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years |
| 99387 | Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older |
| 99395 | Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years |
| 99396 | Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years |
| 99397 | Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older |
| 99401 | Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes |
| 99402 | Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes |
| 99403 | Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes |
| 99404 | Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes |
| 99411 | Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 30 minutes |
| 99412 | Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 60 minutes |
| 99420 | Administration and interpretation of health risk assessment instrument (eg, health hazard appraisal) |
| 99429 | Unlisted preventive medicine service |
| G0438 | Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit |
| G0439 | Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit |
| SNOMED: | |
| Code | Description |
| 12843005 | Subsequent hospital visit by physician (procedure) |
| 18170008 | Subsequent nursing facility visit (procedure) |
| 19681004 | Nursing evaluation of patient and report (procedure) |
| 87790002 | Follow-up inpatient consultation visit (procedure) |
| 90526000 | Initial evaluation and management of healthy individual (procedure) |
| 185349003 | Encounter for “check-up” (procedure) |
| 185463005 | Visit out of hours (procedure) |
| 185465003 | Weekend visit (procedure) |
| 207195004 | History and physical examination with evaluation and management of nursing facility patient (procedure) |
| 270427003 | Patient-initiated encounter (procedure) |
| 270430005 | Provider-initiated encounter (procedure) |
| 308335008 | Patient encounter procedure (procedure) |
| 390906007 | Follow-up encounter (procedure) |
| 406547006 | Urgent follow-up (procedure) |
| 439708006 | Home visit (procedure) |
| 444971000124105 | Annual wellness visit (procedure) |
| 456201000124103 | Medicare Annual Wellness Visit (procedure) |
This is captured by adding a procedure with a valid CPT, HCPCS, or SNOMED code using the Procedure widget in a note.
| CPT/HCPCS: | |
| Code | Description |
| 90791 | Psychiatric diagnostic evaluation |
| 90792 | Psychiatric diagnostic evaluation with medical services |
| 90832 | Psychotherapy, 30 minutes with patient |
| 90834 | Psychotherapy, 45 minutes with patient |
| 90837 | Psychotherapy, 60 minutes with patient |
| 90845 | Psychoanalysis |
| 92002 | Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient |
| 92004 | Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits |
| 92012 | Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient |
| 92014 | Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits |
| 98966 | Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion |
| 98967 | Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion |
| 98968 | Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion |
| 98969 | Online assessment and management service provided by a qualified nonphysician health care professional to an established patient or guardian, not originating from a related assessment and management service provided within the previous 7 days, using the Internet or similar electronic communications network |
| 98970 | Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes |
| 98971 | Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes |
| 98972 | Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes |
| 99201 | Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family. |
| 99202 | Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family. |
| 99203 | Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. |
| 99204 | Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family. |
| 99205 | Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. |
| 99212 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family. |
| 99213 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family. |
| 99214 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. |
| 99215 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family. |
| 99341 | Home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent face-to-face with the patient and/or family. |
| 99342 | Home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. |
| 99343 | Home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family. |
| 99344 | Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. |
| 99345 | Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent face-to-face with the patient and/or family. |
| 99347 | Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family. |
| 99348 | Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. |
| 99349 | Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family. |
| 99350 | Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with the patient and/or family. |
| 99421 | Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes |
| 99422 | Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes |
| 99423 | Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes |
| 99441 | Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion |
| 99442 | Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion |
| 99443 | Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion |
| 99458 | Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes (List separately in addition to code for primary procedure) |
| 97161 | Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family. |
| 97162 | Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family. |
| 97163 | Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family. |
| 97165 | Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family. |
| 97166 | Occupational therapy evaluation, moderate complexity, requiring these components: An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family. |
| 97167 | Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family. |
| 97168 | Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family. |
| G0071 | Payment for communication technology-based services for 5 minutes or more of a virtual (non-face-to-face) communication between an rural health clinic (rhc) or federally qualified health center (fqhc) practitioner and rhc or fqhc patient, or 5 minutes or more of remote evaluation of recorded video and/or images by an rhc or fqhc practitioner, occurring in lieu of an office visit; rhc or fqhc only |
| G2010 | Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment |
| G2012 | Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion |
| G2061 | Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes |
| G2062 | Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes |
| G2063 | Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes |
| SNOMED: | |
| Code | Description |
| 10197000 | Psychiatric interview and evaluation (procedure) |
| 165172002 | Diagnostic psychiatric interview (procedure) |
| 183381005 | General psychotherapy (regime/therapy) |
| 183382003 | Psychotherapy – behavioral (regime/therapy) |
| 183383008 | Psychotherapy – cognitive (regime/therapy) |
| 18512000 | Individual psychotherapy (regime/therapy) |
| 185317003 | Telephone encounter (procedure) |
| 185463005 | Visit out of hours (procedure) |
| 185464004 | Out of hours visit – not night visit (procedure) |
| 185465003 | Weekend visit (procedure) |
| 225929007 | Joint home visit (procedure) |
| 28988002 | Psychoanalysis in depth (procedure) |
| 302242004 | Long-term psychodynamic psychotherapy (regime/therapy) |
| 30346009 | Evaluation and management of established outpatient in office or other outpatient facility (procedure) |
| 304820009 | Developmental psychodynamic psychotherapy (regime/therapy) |
| 304822001 | Psychodynamic-interpersonal psychotherapy (regime/therapy) |
| 314034001 | Psychodynamic psychotherapy (regime/therapy) |
| 314849005 | Telephone contact by consultant (procedure) |
| 315205008 | Bank holiday home visit (procedure) |
| 33849009 | Diagnostic physical therapy procedure (regime/therapy) |
| 3391000175108 | Office visit for pediatric care and assessment (procedure) |
| 359960003 | Ophthalmologic examination and evaluation under general anesthesia, limited (procedure) |
| 36228007 | Ophthalmic examination and evaluation (procedure) |
| 37894004 | Evaluation and management of new outpatient in office or other outpatient facility (procedure) |
| 386472008 | Telephone consultation (procedure) |
| 386473003 | Telephone follow-up (procedure) |
| 38678006 | Client-centered psychotherapy (regime/therapy) |
| 401157001 | Brief solution focused psychotherapy (regime/therapy) |
| 401267002 | Telephone triage encounter (procedure) |
| 410155007 | Occupational therapy assessment (procedure) |
| 410157004 | Occupational therapy management (procedure) |
| 439708006 | Home visit (procedure) |
| 439740005 | Postoperative follow-up visit (procedure) |
| 443730003 | Interpersonal psychotherapy (regime/therapy) |
| 61436009 | Psychoanalysis (procedure) |
| 66902005 | Ophthalmic examination and evaluation, follow-up (procedure) |
| 68338001 | Interactive medical psychiatric diagnostic interview (procedure) |
| 698704008 | Home visit for rheumatology service (procedure) |
| 704126008 | Home visit for anticoagulant drug monitoring (procedure) |
| 75516001 | Psychotherapy (regime/therapy) |
| 78831002 | Comprehensive eye examination (procedure) |
| 79094001 | Initial psychiatric interview with mental status and evaluation (procedure) |
| 90102008 | Social psychotherapy (regime/therapy) |
Denominator Exceptions:
This measure makes an exception for patients who were not screened for tobacco use due to a documented medical reason. In order to meet the requirements for this exception, the appropriate information must be documented in the chart (at least one of the following):
| SNOMED: | |
| Code | Description |
| 27143004 | Patient status determination, pre-terminal (finding) |
| 170969009 | Prognosis bad (finding) |
| 162607003 | Terminal illness – early stage (finding) |
| 162608008 | Terminal illness – late stage (finding) |
| 300936002 | Terminal illness (finding) |
Entered via the Medication button in the note for the first encounter of the measurement period for the patient.
- This is captured by adding a medication not ordered with a valid RXNORM code and attaching a valid SNOMED code for the reason not done using the medication button in a note.
Medical Reason
| SNOMED: | |
| Code | Description |
| 183932001 | Procedure contraindicated (situation) |
| 183964008 | Treatment not indicated (situation) |
| 183966005 | Drug treatment not indicated (situation) |
| 266721009 | Absent response to treatment (situation) |
| 269191009 | Late effect of medical and surgical care complication (disorder) |
| 31438003 | Drug resistance (disorder) |
| 35688006 | Complication of medical care (disorder) |
| 397745006 | Medical contraindication (finding) |
| 407563006 | Treatment not tolerated (situation) |
| 410534003 | Not indicated (qualifier value) |
| 410536001 | Contraindicated (qualifier value) |
| 416098002 | Allergy to drug (finding) |
| 428119001 | Procedure not indicated (situation) |
| 59037007 | Intolerance to drug (finding) |
| 62014003 | Adverse reaction caused by drug (disorder) |
| 79899007 | Drug interaction (finding) |
Patient Reason
| SNOMED | Description |
| 105480006 | Refusal of treatment by patient (situation) |
| 160932005 | Financial problem (finding) |
| 160934006 | Financial circumstances change (finding) |
| 182890002 | Patient requests alternative treatment (finding) |
| 182895007 | Drug declined by patient (situation) |
| 182897004 | Drug declined by patient – side effects (situation) |
| 182900006 | Drug declined by patient – patient beliefs (situation) |
| 182902003 | Medication declined by patient – cannot pay script (situation) |
| 183944003 | Procedure refused (situation) |
| 183945002 | Procedure refused for religious reason (situation) |
| 184081006 | Patient has moved away (finding) |
| 185479006 | Patient dissatisfied with result (finding) |
| 185481008 | Dissatisfied with doctor (finding) |
| 224187001 | Variable income (finding) |
| 225928004 | Patient self-discharge against medical advice (procedure) |
| 713247000 | Procedure discontinued by patient (situation) |
| 266710000 | Drugs not taken/completed (situation) |
| 266966009 | Family illness (situation) |
| 275694009 | Patient defaulted from follow-up (finding) |
| 275936005 | Patient noncompliance – general (situation) |
| 281399006 | Did not attend (finding) |
| 310343007 | Further opinion sought (finding) |
| 373787003 | Treatment delay – patient choice (finding) |
| 406149000 | Medication refused (situation) |
| 408367005 | Patient forgets to take medication (finding) |
| 413310006 | Patient non-compliant – refused access to services (situation) |
| 413311005 | Patient non-compliant – refused intervention / support (situation) |
| 413312003 | Patient non-compliant – refused service (situation) |
| 416432009 | Procedure discontinued by patient (situation) |
| 423656007 | Income insufficient to buy necessities (finding) |
| 424739004 | Income sufficient to buy only necessities (finding) |
| 443390004 | Refused (qualifier value) |
System Reason
| SNOMED | Description |
| 107724000 | Patient transfer (procedure) |
| 182856006 | Drug not available – out of stock (finding) |
| 182857002 | Drug not available-off market (finding) |
| 185335007 | Appointment canceled by hospital (finding) |
| 224194003 | Not entitled to benefits (finding) |
| 224198000 | Delay in receiving benefits (finding) |
| 224199008 | Loss of benefits (finding) |
| 242990004 | Drug not available for administration (event) |
| 266756008 | Medical care unavailable (situation) |
| 270459005 | Patient on waiting list (finding) |
| 309017000 | Referred to doctor (finding) |
| 309846006 | Treatment not available (situation) |
| 419808006 | Finding related to health insurance issues (finding) |
| 424553001 | Uninsured medical expenses (finding) |
Required Data Elements for the Numerator:
AND, if the patient is a tobacco user, at least ONE of the following must also be documented:
This is captured by prescribing or renewing a medication with a valid RXNORM code.
| RXNORM: | |
| Code | Description |
| 1232585 | 24 HR bupropion hydrochloride 450 MG Extended Release Oral Tablet |
| 1302827 | 24 HR phentermine 7.5 MG / topiramate 46 MG Extended Release Oral Capsule |
| 1302839 | 24 HR phentermine 3.75 MG / topiramate 23 MG Extended Release Oral Capsule |
| 1302850 | 24 HR phentermine 15 MG / topiramate 92 MG Extended Release Oral Capsule |
| 1436239 | 24 HR topiramate 50 MG Extended Release Oral Capsule |
| 1437278 | 24 HR topiramate 25 MG Extended Release Oral Capsule |
| 1437283 | 24 HR topiramate 100 MG Extended Release Oral Capsule |
| 1437288 | 24 HR topiramate 200 MG Extended Release Oral Capsule |
| 1494769 | Sprinkle 24 HR topiramate 150 MG Extended Release Oral Capsule |
| 151226 | topiramate 50 MG Oral Tablet |
| 1551468 | 12 HR bupropion hydrochloride 90 MG / naltrexone hydrochloride 8 MG Extended Release Oral Tablet |
| 1797886 | nicotine 0.5 MG/ACTUAT Metered Dose Nasal Spray |
| 1801289 | Smoking Cessation 12 HR bupropion hydrochloride 150 MG Extended Release Oral Tablet |
| 1812419 | Sprinkle 24 HR topiramate 200 MG Extended Release Oral Capsule |
| 1812421 | Sprinkle 24 HR topiramate 25 MG Extended Release Oral Capsule |
| 1812425 | Sprinkle 24 HR topiramate 50 MG Extended Release Oral Capsule |
| 1812427 | Sprinkle 24 HR topiramate 100 MG Extended Release Oral Capsule |
| 198029 | 24 HR nicotine 0.583 MG/HR Transdermal System |
| 198030 | 24 HR nicotine 0.875 MG/HR Transdermal System |
| 198031 | 24 HR nicotine 0.292 MG/HR Transdermal System |
| 198045 | nortriptyline 10 MG Oral Capsule |
| 198046 | nortriptyline 50 MG Oral Capsule |
| 198047 | nortriptyline 75 MG Oral Capsule |
| 199888 | topiramate 25 MG Oral Tablet |
| 199889 | topiramate 100 MG Oral Tablet |
| 199890 | topiramate 200 MG Oral Tablet |
| 205315 | topiramate 25 MG Oral Capsule |
| 205316 | topiramate 15 MG Oral Capsule |
| 250983 | nicotine 4 MG Inhalation Solution |
| 311975 | nicotine 4 MG Chewing Gum |
| 312036 | nortriptyline 2 MG/ML Oral Solution |
| 314119 | nicotine 2 MG Chewing Gum |
| 317136 | nortriptyline 25 MG Oral Capsule |
| 359817 | nicotine 2 MG Oral Lozenge |
| 359818 | nicotine 4 MG Oral Lozenge |
| 636671 | varenicline 0.5 MG Oral Tablet |
| 636676 | varenicline 1 MG Oral Tablet |
| 749289 | {11 (varenicline 0.5 MG Oral Tablet) / 42 (varenicline 1 MG Oral Tablet) } Pack |
| 749788 | {56 (varenicline 1 MG Oral Tablet) } Pack |
| 892244 | {14 (24 HR nicotine 0.292 MG/HR Transdermal System) / 14 (24 HR nicotine 0.583 MG/HR Transdermal System) / 28 (24 HR nicotine 0.875 MG/HR Transdermal System) } Pack |
| 993503 | 12 HR bupropion hydrochloride 100 MG Extended Release Oral Tablet |
| 993518 | 12 HR bupropion hydrochloride 150 MG Extended Release Oral Tablet |
| 993536 | 12 HR bupropion hydrochloride 200 MG Extended Release Oral Tablet |
| 993541 | 24 HR bupropion hydrochloride 150 MG Extended Release Oral Tablet |
| 993557 | 24 HR bupropion hydrochloride 300 MG Extended Release Oral Tablet |
| 993687 | bupropion hydrochloride 100 MG Oral Tablet |
| 993691 | bupropion hydrochloride 75 MG Oral Tablet |
| 998671 | 168 HR clonidine 0.00417 MG/HR Transdermal System |
| 998675 | 168 HR clonidine 0.00833 MG/HR Transdermal System |
| 998679 | 168 HR clonidine 0.0125 MG/HR Transdermal System |
ADDITIONAL INFORMATION:
- In order for successful calculation of this measure, the most recent version of ChartMaker Clinical 2018 must be used.
- The codes used for the numerator must be documented within the last 24 months prior to the measurement END date.
- The additional fields in the smoking button are optional.
- The only data used to determine the denominator is data from ChartMaker Clinical. If a patient encounter was not entered into Clinical, that encounter is not included in the denominator for the statistical calculations on the MIPS Dashboard. Please add these additional patients to the denominator and recalculate the percentage for Attestation purposes.