Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (2024)

eCQMs / NQF #:	CMS138v12 / XXXX
Measure:	Percentage of patients aged 12 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: Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period. Percentage of patients aged 12 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. Percentage of patients aged 12 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.
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.
Denominator:	Population 1: All patients aged 12 years and older seen for at least two visits or at least one preventive visit during the measurement period. Population 2: All patients aged 12 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 during the measurement period and identified as a tobacco user. Population 3: All patients aged 12 years and older seen for at least two visits or at least one preventive visit during the measurement period.
Denominator Exclusions:	Exclude patients who are in hospice care for any part of the measurement period.
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 12 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:

Two or more visits during the measurement period

This is captured by adding a procedure with a valid CPT or SNOMED code using the Procedure widget in a note.

Health Behavior Assessment or Intervention

CPT:
Code	Description
96156	Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making)
96158	Health behavior intervention, individual, face-to-face; initial 30 minutes

Home Healthcare Services

CPT:
Code	Description
99341	Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.
99342	Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
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 or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.
99345	Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.
99347	Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.
99348	Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
99349	Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.
99350	Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.

SNOMED:
Code	Description
225929007	Joint home visit (procedure)
315205008	Bank holiday home visit (procedure)
439708006	Home visit (procedure)
698704008	Home visit for rheumatology service (procedure)
704126008	Home visit for anticoagulant drug monitoring (procedure)

Occupational Therapy Evaluation

SNOMED:
Code	Description
228653003	Occupational therapy home visit (regime/therapy)
410155007	Occupational therapy assessment (procedure)
410156008	Occupational therapy education (procedure)
410157004	Occupational therapy management (procedure)
423602000	Occupational therapy surveillance (regime/therapy)
424574000	Occupational therapy education, guidance, counseling (procedure)
59694001	Occupational social therapy (regime/therapy)
84478008	Occupational therapy (regime/therapy)

CPT:
Code	Description
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.

Office Visit

CPT:
Code	Description
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 a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.
99203	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.
99204	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.
99205	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.
99212	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.
99213	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.
99214	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.
99215	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.

SNOMED:
Code	Description
185463005	Visit out of hours (procedure)
185464004	Out of hours visit – not night visit (procedure)
185465003	Weekend visit (procedure)
30346009	Evaluation and management of established outpatient in office or other outpatient facility (procedure)
3391000175108	Office visit for pediatric care and assessment (procedure)
37894004	Evaluation and management of new outpatient in office or other outpatient facility (procedure)
439740005	Postoperative follow-up visit (procedure)

Ophthalmological Services

SNOMED:
Code	Description
359960003	Ophthalmologic examination and evaluation under general anesthesia, limited (procedure)
36228007	Ophthalmic examination and evaluation (procedure)
66902005	Ophthalmic examination and evaluation, follow-up (procedure)
78831002	Comprehensive eye examination (procedure)

CPT:
Code	Description
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

Physical Therapy Evaluation

SNOMED:
Code	Description
183326003	Combined physical therapy (regime/therapy)
33849009	Diagnostic physical therapy procedure (regime/therapy)
410158009	Physical therapy assessment (procedure)
410159001	Physical therapy education (procedure)
410160006	Physical therapy management (procedure)
424203006	Physical therapy education, guidance and counseling (procedure)
424291000	Physical therapy surveillance (regime/therapy)

CPT:
Code	Description
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.
97164	Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a 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.

Psych Visit Diagnostic Evaluation

SNOMED:
Code	Description
10197000	Psychiatric interview and evaluation (procedure)
165172002	Diagnostic psychiatric interview (procedure)
68338001	Interactive medical psychiatric diagnostic interview (procedure)
79094001	Initial psychiatric interview with mental status and evaluation (procedure)

SNOMED:
Code	Description
90791	Psychiatric diagnostic evaluation
90792	Psychiatric diagnostic evaluation with medical services

Psych Visit Psychotherapy

SNOMED:
Code	Description
183381005	General psychotherapy (regime/therapy)
183382003	Psychotherapy – behavioral (regime/therapy)
183383008	Psychotherapy – cognitive (regime/therapy)
18512000	Individual psychotherapy (regime/therapy)
302242004	Long-term psychodynamic psychotherapy (regime/therapy)
304820009	Developmental psychodynamic psychotherapy (regime/therapy)
304822001	Psychodynamic-interpersonal psychotherapy (regime/therapy)
314034001	Psychodynamic psychotherapy (regime/therapy)
38678006	Client-centered psychotherapy (regime/therapy)
401157001	Brief solution focused psychotherapy (regime/therapy)
443730003	Interpersonal psychotherapy (regime/therapy)
75516001	Psychotherapy (regime/therapy)
90102008	Social psychotherapy (regime/therapy)

SNOMED:
Code	Description
90832	Psychotherapy, 30 minutes with patient
90834	Psychotherapy, 45 minutes with patient
90837	Psychotherapy, 60 minutes with patient

Psychoanalysis

SNOMED:
Code	Description
28988002	Psychoanalysis in depth (procedure)
61436009	Psychoanalysis (procedure)

CPT:
Code	Description
90845	Psychoanalysis

Speech and Hearing Evaluation

SNOMED:
Code	Description
26342005	Medical evaluation for speech, language and/or hearing problems (regime/therapy)
41375007	Medical evaluation of hearing problem (procedure)
77837000	Medical evaluation of speech, language and hearing problem (procedure)
91515000	Special audiologic evaluation for functional hearing loss (procedure)

CPT:
Code	Description
92521	Evaluation of speech fluency (eg, stuttering, cluttering)
92522	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)
92523	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)
92524	Behavioral and qualitative analysis of voice and resonance
92540	Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording
92557	Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined)
92625	Assessment of tinnitus (includes pitch, loudness matching, and masking)

Telephone Visits

CPT:
Code	Description
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
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

SNOMED:
Code	Description
185317003	Telephone encounter (procedure)
314849005	Telephone contact by consultant (procedure)
386472008	Telephone consultation (procedure)
386473003	Telephone follow-up (procedure)
401267002	Telephone triage encounter (procedure)

Online Assessment

CPT:
Code	Description
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
98980	Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; first 20 minutes
98981	Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; each additional 20 minutes (List separately in addition to code for primary procedure)
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
99444	Online evaluation and management service provided by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient or guardian, not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network
99457	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; first 20 minutes
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)

HCPCS:
Code	Description
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
G2250	Remote assessment 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 service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment
G2251	Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of clinical discussion
G2252	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; 11-20 minutes of medical discussion

At least one Preventive Care Service, or Annual Wellness Visit during the measurement period

This is captured by adding a procedure with a valid CPT or SNOMED code using the Procedure widget in a note.

Annual Wellness Visit

HCPCS:
Code	Description
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
444971000124105	Annual wellness visit (procedure)
456201000124103	Medicare annual wellness visit (procedure)

Preventive Care Services, 18 years old and Up

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

Preventive Care Services Group Counseling

CPT:
Code	Description
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

Unlisted preventive medicine service

CPT:
Code	Description
99429	Unlisted preventive medicine service

Preventive Care Services Individual Counseling

CPT:
Code	Description
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

Postoperative follow-up visit

CPT:
Code	Description
99024	Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure

Nutrition Services

CPT:
Code	Description
97802	Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
97803	Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
97804	Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes

HCPCS:
G0270	Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes
G0271	Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes
G0447	Face-to-face behavioral counseling for obesity, 15 minutes
S9449	Weight management classes, non-physician provider, per session
S9452	Nutrition classes, non-physician provider, per session
S9470	Nutritional counseling, dietitian visit

SNOMED:
11816003	Diet education (procedure)
14051000175103	Dietary education for cardiovascular disorder (procedure)
183059007	High fiber diet education (procedure)
183060002	Low residue diet education (procedure)
183061003	Low fat diet education (procedure)
183062005	Low cholesterol diet education (procedure)
183063000	Low salt diet education (procedure)
183065007	Low carbohydrate diet education (procedure)
183066008	Low protein diet education (procedure)
183067004	High protein diet education (procedure)
183070000	Vegetarian diet education (procedure)
183071001	Vegan diet education (procedure)
226067002	Food hygiene education (procedure)
266724001	Weight-reducing diet education (procedure)
275919002	Weight loss advised (situation)
281085002	Sugar-free diet education (procedure)
284352003	Obesity diet education (procedure)
305849009	Seen by dietetics service (finding)
305850009	Seen by community-based dietetics service (finding)
305851008	Seen by hospital-based dietetics service (finding)
306163007	Referral to dietetics service (procedure)
306164001	Referral to community-based dietetics service (procedure)
306165000	Referral to hospital-based dietetics service (procedure)
306626002	Discharge from dietetics service (procedure)
306627006	Discharge from hospital dietetics service (procedure)
306628001	Discharge from community dietetics service (procedure)
313210009	Fluid intake education (procedure)
370847001	Dietary needs education (procedure)
386464006	Prescribed diet education (procedure)
404923009	Weight gain advised (situation)
408910007	Enteral feeding education (procedure)
410171007	Nutrition care education (procedure)
410177006	Special diet education (procedure)
410200000	Weight control education (procedure)
428461000124101	Referral to nutrition professional (procedure)
428691000124107	Vitamin K dietary intake education (procedure)
429095004	Dietary education for weight gain (procedure)
431482008	Dietary education for competitive athlete (procedure)
441041000124100	Counseling about nutrition (regime/therapy)
441201000124108	Counseling about nutrition using cognitive behavioral theoretical approach (regime/therapy)
441231000124100	Counseling about nutrition using health belief model (regime/therapy)
441241000124105	Counseling about nutrition using social learning theory approach (regime/therapy)
441251000124107	Counseling about nutrition using transtheoretical model and stages of change approach (regime/therapy)
441261000124109	Counseling about nutrition using motivational interviewing technique (regime/therapy)
441271000124102	Counseling about nutrition using goal setting strategy (regime/therapy)
441281000124104	Counseling about nutrition using self-monitoring strategy (regime/therapy)
441291000124101	Counseling about nutrition using problem solving strategy (regime/therapy)
441301000124100	Counseling about nutrition using social support strategy (regime/therapy)
441311000124102	Counseling about nutrition using stress management strategy (regime/therapy)
441321000124105	Counseling about nutrition using stimulus control strategy (regime/therapy)
441331000124108	Counseling about nutrition using cognitive restructuring strategy (regime/therapy)
441341000124103	Counseling about nutrition using relapse prevention strategy (regime/therapy)
441351000124101	Counseling about nutrition using rewards and contingency management strategy (regime/therapy)
443288003	Lifestyle education regarding diet (procedure)
445291000124103	Nutrition-related skill education (procedure)
445301000124102	Content-related nutrition education (procedure)
445331000124105	Nutrition-related laboratory result interpretation education (procedure)
445641000124105	Technical nutrition education (procedure)
609104008	Educated about weight management (situation)
61310001	Nutrition education (procedure)
698471002	Patient advised about weight management (situation)
699827002	Dietary education about fluid restriction (procedure)
699829004	High energy diet education (procedure)
699830009	Food fortification education (procedure)
699849008	Healthy eating education (procedure)
700154005	Seen in weight management clinic (finding)
700258004	Dietary education about vitamin intake (procedure)
705060005	Diet education about mineral intake (procedure)
710881000	Education about eating pattern (procedure)

And, to be included in Population 2:

Smoking history documented in the Smoking Button (in a note), and patient identified as a tobacco user during the measurement period

Denominator Exclusions:

Denominator exclusions include patients who are in hospice care for any part of the measurement period.

In order to meet the requirements for this exclusion, the aforementioned must be documented in the chart and start before or during the measurement period:

Hospice Services during the measurement period

Hospice Services is captured by having an Inpatient Encounter with a Discharge for Hospice Care, or a Hospice Encounter, or Hospice Care Ambulatory Procedure Ordered or Performed, or a Hospice Diagnosis, or a Hospice Assessment with a result of Yes, during the measure period. In order to meet the requirements for the Hospice exclusion, at least one of the aforementioned must be documented in the chart and start before or during the measurement period:

Inpatient Encounter (SNOMED) during the measurement period that ends with Discharge for Hospice Care (SNOMED)
This is captured by adding a procedure with a valid SNOMED code using the Procedure widget in a note.

Encounter – Inpatient

SNOMED:
Code	Description
183452005	Emergency hospital admission (procedure)
32485007	Hospital admission (procedure)
8715000	Hospital admission, elective (procedure)

and

Discharge Code

SNOMED:
Code	Description
428361000124107	Discharge to home for hospice care (procedure)
428371000124100	Discharge to healthcare facility for hospice care (procedure)

Hospice Encounter (SNOMED or HCPCS) during or overlapping the measurement period

This is captured by adding a procedure with a valid SNOMED code using the Procedure widget in a note.

SNOMED:
Code	Description
183919006	Urgent admission to hospice (procedure)
183920000	Routine admission to hospice (procedure)
183921001	Admission to hospice for respite (procedure)
305336008	Admission to hospice (procedure)
305911006	Seen in hospice (finding)
385765002	Hospice care management (procedure)

HCPCS:
Code	Description
G9473	Services performed by chaplain in the hospice setting, each 15 minutes
G9474	Services performed by dietary counselor in the hospice setting, each 15 minutes
G9475	Services performed by other counselor in the hospice setting, each 15 minutes
G9476	Services performed by volunteer in the hospice setting, each 15 minutes
G9477	Services performed by care coordinator in the hospice setting, each 15 minutes
G9478	Services performed by other qualified therapist in the hospice setting, each 15 minutes
G9479	Services performed by qualified pharmacist in the hospice setting, each 15 minutes
Q5003	Hospice care provided in nursing long term care facility (ltc) or non-skilled nursing facility (nf)
Q5004	Hospice care provided in skilled nursing facility (snf)
Q5005	Hospice care provided in inpatient hospital
Q5006	Hospice care provided in inpatient hospice facility
Q5007	Hospice care provided in long term care facility
Q5008	Hospice care provided in inpatient psychiatric facility
Q5010	Hospice home care provided in a hospice facility
S9126	Hospice care, in the home, per diem
T2042	Hospice routine home care; per diem
T2043	Hospice continuous home care; per hour
T2044	Hospice inpatient respite care; per diem
T2045	Hospice general inpatient care; per diem
T2046	Hospice long term care, room and board only; per diem

Hospice Care Ambulatory Procedure (SNOMED, CPT, or HCPCS) during or overlapping the measurement period
This is captured by adding a procedure with a valid SNOMED, CPT, or HCPCS code using the Procedure widget in a note.

SNOMED:
Code	Description
385763009	Hospice care (regime/therapy)
385765002	Hospice care management (procedure)

CPT:
Code	Description
99377	Supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes
99378	Supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more

HCPCS:
Code	Description
G0182	Physician supervision of a patient under a medicare-approved hospice (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communication (including telephone calls) with other health care professionals involved in the patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more

Hospice Diagnosis (SNOMED) during or overlapping the measure period

This is captured by adding a diagnosis with a valid SNOMED code using the Diagnosis widget in a note.

SNOMED:
Code	Description
170935008	Full care by hospice (finding)
170936009	Shared care – hospice and general practitioner (finding)
305911006	Seen in hospice (finding)

Hospice Assessment overlapping the measure period

To qualify for the Hospice Assessment denominator exclusion, the patient must have a Hospice Assessment with a LOINC code of 45755-6 with a result finding of Yes, with a SNOMED code 373066001, that overlaps the measurement period.

This can be achieved by configuring a checklist with a Hospice Care checklist item, and then selecting that checklist item for applicable patients.

First, create or modify a procedure/result condition via Edit > System Tables > All Conditions.

In the Conditions Properties dialog, be sure to select the Procedure option and attach the 45755-6 code in the corresponding LOINC Code field.

Check the Result option, the 45755-6 code should also appear in the corresponding LOINC Code field.

Next, in the Template Editor, access the template you want to create or modify a checklist to include the Hospice Care item.

In the checklist, right click and select Insert finding…

In the Finding dialog, configure an applicable Heading; then and create Normal finding, for example Receiving Hospice Care; and then click Tag and attach the procedure/result configured above.

Click the SNOMED button and then attach the 373066001 SNOMED code to the tagged item.

After the checklist has been configured with the Hospice Care, and configured for the note template, whenever a patient is receiving hospice care, simply select this option in the checklist for the patient.

Required Data Elements for the Numerator – Population 1:

Smoking history documented in the Smoking Button (in a note) during the measurement period

Required Data Elements for the Numerator – Population 2:
At least one of the following:

Cessation Materials/Counseling Provided documented in a note during the measurement period or 6 months prior to the measurement period

This is captured by checking the Cessation materials/counseling provided option in the Smoking widget of a chart note, and configuring the corresponding date.

This can also be captured by adding a procedure with a valid SNOMED or CPT code using the Procedure widget in a note.

SNOMED:
Code	Description
1148687006	Education about cessation of electronic cigarette use (procedure)
171055003	Pregnancy smoking education (procedure)
185795007	Stop smoking monitoring verbal invite (procedure)
185796008	Stop smoking monitoring telephone invite (procedure)
225323000	Smoking cessation education (procedure)
225324006	Smoking effects education (procedure)
310429001	Smoking monitoring invitation (procedure)
315232003	Referral to stop-smoking clinic (procedure)
384742004	Smoking cessation assistance (regime/therapy)
395700008	Referral to smoking cessation advisor (procedure)
449841000124108	Referral to tobacco use cessation clinic (procedure)
449851000124105	Referral to tobacco use cessation counselor (procedure)
449861000124107	Referral to tobacco use cessation counseling program (procedure)
449871000124100	Referral to tobacco use quit line (procedure)
702388001	Tobacco use cessation education (procedure)
710081004	Smoking cessation therapy (regime/therapy)
711028002	Counseling about tobacco use (procedure)
713700008	Smoking cessation drug therapy (regime/therapy)

CPT:
Code	Description
99406	Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
99407	Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes

This can also be captured by adding a diagnsois with a valid ICD-10 code using the Diagnosis widget in a note.

ICD-10:
Code	Description
Z71.6	Tobacco abuse counseling

Medication for Tobacco Use Cessation Pharmacotherapy prescribed during the measurement period or 6 months prior to the measurement period

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
1313059	24 HR phentermine 11.25 MG / topiramate 69 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

Required Data Elements for the Numerator – Population 3:

Smoking history documented in the Smoking Button (in a note) during the measurement period, indicating Tobacco Non-User

Smoking history documented in the Smoking Button (in a note) during the measurement period, indicating Tobacco User

AND