eCQM / NQF #: CMS138v7 / 0028
Measure: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user. Three rates are reported: a. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months; b. Percentage of patients aged 18 years and older who were screened for tobacco use and identified as a tobacco user who received tobacco cessation intervention; c. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user.
Numerator: Population 1: Patients who were screened for tobacco use at least once within 24 months
Population 2: Patients who received tobacco cessation intervention Population 3: Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user
Denominator: Population 1: Equals Initial Population
Population 2: Equals Initial Population who were screened for tobacco use and identified as a tobacco user
Population 3: Equals Initial Population
Denominator Exceptions: Population 1: Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reason)
Population 2: Documentation of medical reason(s) for not providing tobacco cessation intervention (eg, 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 (eg, 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:  

Required Data Elements for the Numerator: 

AND, if the patient is a tobacco user, at least ONE of the following must also be documented:  

EXCEPTION DETAILS: 

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):

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 the ChartMaker Clinical Module. If a patient encounter was not entered into the ChartMaker Clinical Module, that encounter is not included in the denominator for the statistical calculations on the Meaningful Use Dashboard. Please add these additional patients to the denominator and recalculate the percentage for Attestation purposes.