CMS138v12 – Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

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

A qualifying visit in this case can be either of the following:

• Health behavior intervention, individual, face-to-face; initial 30 minutes
• Health behavior assessment, or re-assessment (i.e., health-focused clinical interview, behavioral observations, clinical decision making)
• Home Healthcare Services
• Occupational Therapy Evaluation
• Office Visit
• Ophthalmological Services
• Physical Therapy Evaluation
• Psych Visit Diagnostic Evaluation
• Psych Visit Psychotherapy
• Psychoanalysis
• Speech and Hearing Evaluation
• Telephone Visits
• Online Assessments

Furthermore, a ‘preventive’ qualifying visit includes:

• Annual Wellness Visit
• Preventive Care Services Established Office Visit, 18 and Up
• Preventive Care Services Group Counseling
• Unlisted preventive medicine service
• Preventive Care Services Individual Counseling
• 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
• Preventive Care Services Initial Office Visit, 18 and Up

Equals Initial Population

Patients who were screened for tobacco use at least once during the measurement period.

Equals Initial Population + patients who were screened for tobacco use during the measurement period and identified as a tobacco user.

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

The tobacco cessation intervention in this case can include either of the following:

• Tobacco Cessation Counseling
• Tobacco Cessation Pharmacotherapy

Equals Initial Population

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.

Patients who are in hospice care for any part of the measurement period.

For Denominators 1 & 3:

To record the encounters, navigate to Patient > Provider Note > Create Superbill. Under the ‘Procedure- CPTs’ heading, enter the encounter code.

For Denominator 2:

• To record the encounters, navigate to Patient > Provider Note > Create Superbill. Under the ‘Procedure- CPTs’ heading, enter the encounter code.

• To document a patient’s identification as a tobacco user, use the workflow Patient > Clinical > History > + Social. Here, select the ‘Tobacco’ tab and use the drop down for ‘Smoking Status’ to choose the relevant smoking status of the patient. Once done, click ‘Save’.

For Numerator  1:

• Identifying patients as ‘Smoker’ or ‘Non-smoker’ can be done via Patient > Clinical > History > + Social. Here, select the ‘Tobacco’ tab and use the drop down for ‘Smoking Status’ to choose the relevant smoking status of the patient. Once done, click ‘Save’.
• To document ‘tobacco use screening’ as an assessment, head over to Patient > Provider Note > Evaluations. Here, search for a relevant assessment and from the ‘Status’ drop-down select ‘Performed’.

For Numerator 2:

• Documentation of tobacco cessation counseling can be done through Patient > Provider Notes > Evaluations. Click ‘Add’ and search for the relevant evaluation. From the ‘Status’ dropdown, select ‘Performed’. Once done, click ‘Save’.

• For ordering tobacco cessation pharmacotherapy, navigate to Patient > Provider Notes > Prescription. Click ‘Add’ and search for the relevant medication. Fill out the relevant details and once done, click ‘Prescribe’.

For Numerator  3:

• Identifying patients as ‘Smoker’ or ‘Non-smoker’ can be done via Patient > Clinical > History > + Social. Here, select the ‘Tobacco’ tab and use the drop down for ‘Smoking Status’ to choose the relevant smoking status of the patient. Once done, click ‘Save’.
• To document ‘tobacco use screening’ as an assessment, head over to Patient > Provider Note > Evaluations. Here, search for a relevant assessment and from the ‘Status’ drop-down select ‘Performed’.
• Documentation of tobacco cessation counseling can be done through Patient > Provider Note > Evaluations. Click ‘Add’ and search for the relevant evaluation. From the ‘Status’ dropdown, select ‘Performed’. Once done, click ‘Save’.
• For ordering tobacco cessation pharmacotherapy, navigate to Patient > Provider Note > Prescription. Click ‘Add’ and search for the relevant medication. Fill out the relevant details and once done, click ‘Prescribe’.

For Denominator Exclusions:

• To document that a patient is receiving hospice care outside of a hospital or long-term care facility, navigate to Patient > Provider Note > Evaluations. Use the below mentioned codes to order or perform an intervention:
  • 385763009: Hospice Care (Regime/Therapy)
  • 385765002: Hospice Care Management (Procedure)

• To document an inpatient encounter, navigate to Patient > Provider Note > Evaluations.

• To document a hospice care assessment, follow the workflow Patient > Provider Note > Evaluations. Click ‘Add’ and search for ‘Hospice Care [Minimum Data Set]’. Then select ‘Performed’ from the ‘Status’ dropdown and ‘Yes’ from the ‘Result’ field.

• A hospice encounter can be documented through Patient > Provider Note > Evaluations or Patient > Provider Note > Create Superbill.