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2021 MIPS Measure #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Quality ID 226
eMeasure ID CMS138v9
NQF 0028
High Priority Measure No
Specifications EHR Registry
Measure Type Process
Specialty Allergy/Immunology Audiology Cardiology Clinical Social Work Dermatology Endocrinology Family Medicine Gastroenterology General Surgery Internal Medicine Mental/Behavioral Health Neurology Neurosurgery Obstetrics/Gynecology Oncology Ophthalmology Orthopedic Surgery Otolaryngology Physical Medicine Physical Therapy/Occupational Therapy Plastic Surgery Podiatry Preventive Medicine Pulmonology Rheumatology Speech/Language Pathology Thoracic Surgery Urgent Care Urology Vascular Surgery

Measure Description

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months AND who received tobacco cessation intervention if identified as a tobacco user

 

Instructions

This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. This measure is intended to reflect the quality of services provided for preventive screening for tobacco use. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who provided the measure-specific denominator coding. For this implementation of the measure, the 12 month look back period includes the program year and the year prior. For Quality Payment Program (QPP) 2021, the 12 month period would be from 1/1/2021-12/31/2021.

This measure will be calculated with 3 performance rates:

1) Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months
2) Percentage of patients aged 18 years and older who were identified as a tobacco user who received tobacco cessation intervention
3) Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months AND who received tobacco cessation intervention if identified as a tobacco user

The denominator of submission criteria 2 is a subset of the resulting numerator for submission criteria 1, as submission criteria 2 is limited to assessing if patients identified as tobacco users received an appropriate tobacco cessation intervention. For all patients, submission criteria 1 and 3 are applicable, but submission criteria 2 will only be applicable for those patients who are identified as tobacco users. Therefore, data for every patient that meets the age and encounter requirements will only be submitted for submission criteria 1 and 3, whereas data submitted for submission criteria 2 will be for a subset of patients who meet the age and encounter requirements, as the denominator has been further limited to those who were identified as tobacco users.

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

Measure Submission Type:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

 

THERE ARE THREE SUBMISSION CRITERIA FOR THIS MEASURE:

1) All patients who were screened for tobacco use

AND

2) All patients who were identified as a tobacco user and who received tobacco cessation intervention

AND

3) All patients who were screened for tobacco use and, if identified as a tobacco user received tobacco cessation intervention, or identified as a tobacco non-user

This measure contains three submission criteria which aim to identify patients who were screened for tobacco use (submission criteria 1), patients who were identified as tobacco users and who received tobacco cessation intervention (submission criteria 2), and a comprehensive look at the overall performance on tobacco screening and cessation intervention (submission criteria 3). By separating this measure into various submission criteria, the MIPS eligible professional or MIPS eligible clinician will be able to better ascertain where gaps in performance exist, and identify opportunities for improvement. The overall rate (submission criteria 3) can be utilized to compare performance to published versions of this measure prior to the 2018 performance year, when the measure had a single performance rate. For accountability reporting in the CMS MIPS program, the rate for submission criteria 2 is used for performance.

 

 

Submission Criteria 1: All patients who were screened for tobacco us

Denominator (Submission Criteria 1)

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

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years

AND

At least two patient encounters during the performance period (CPT): 90791, 90792, 90832, 90834, 90837, 90845, 92002, 92004, 92012, 92014, 92521, 92522, 92523, 92524, 92540, 92557, 92625, 96156, 96158, 97161, 97162, 97163, 97165, 97166, 97167, 97168, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350

OR

At least one preventive encounter during the performance period (CPT or HCPCS): 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, G0438, G0439

 

Numerator (Submission Criteria 1)

Patients who were screened for tobacco use at least once within 12 months

Definitions:

Tobacco Use – Includes any type of tobacco.

NUMERATOR NOTE: To satisfy the intent of this measure, a patient must have at least one tobacco use screening during the 12-month period. If a patient has multiple tobacco use screenings during the 12-month period, only the most recent screening, which has a documented status of tobacco user or tobacco non-user, will be used to satisfy the measure requirements.

In the event that a patient is screened for tobacco use and tobacco status is unknown, submit G9905. Denominator Exception(s) are determined on the date of the most recent denominator eligible encounter for all submission criteria.

Numerator Options:

Performance Met: Patient screened for tobacco use AND identified as a tobacco user (G9902)

OR

Performance Met: Patient screened for tobacco use AND identified as a tobacco non-user (G9903)

OR

Denominator Exception: Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reason) (G9904)

OR

Performance Not Met: Patient not screened for tobacco use, reason not given (G9905)

 


Submission Criteria 2: All patients who were identified as a tobacco user and who received tobacco cessation intervention

Denominator (Submission Criteria 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

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B PFS. These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years

AND

All eligible instances when G9902 is submitted for Performance Met (patient screened for tobacco use and identified as a tobacco user) in the numerator of Submission Criteria 1

AND

At least two patient encounters during the performance period (CPT): 90791, 90792, 90832, 90834, 90837, 90845, 92002, 92004, 92012, 92014, 92521, 92522, 92523, 92524, 92540, 92557, 92625, 96156, 96158, 97161, 97162, 97163, 97165, 97166, 97167, 97168, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350

OR

At least one preventive encounter during the performance period (CPT or HCPCS): 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, G0438, G0439

 

Numerator (Submission Criteria 2)

Patients who received tobacco cessation intervention

Definitions:

Tobacco Cessation Intervention Includes brief counseling (3 minutes or less), and/or pharmacotherapy. Note: For the purpose of this measure, brief counseling (e.g., minimal and intensive advice/counseling interventions conducted both in person and over the phone) qualifies for the numerator. Written self-help materials (e.g., brochures, pamphlets) and complementary/alternative therapies do not qualify for the numerator. Brief counseling also may be of longer duration or be performed more frequently, as evidence shows there is a dose-response relationship between the intensity of counseling provided (either length or frequency) and tobacco cessation rates (U.S. Preventive Services Task Force, 2015).

NUMERATOR NOTE: If a patient uses any type of tobacco (i.e., smokes or uses smokeless tobacco), the expectation is that they should receive tobacco cessation intervention: either counseling and/or pharmacotherapy.

This measure defines tobacco cessation counseling as lasting 3 minutes or less. Services typically provided under CPT codes 99406 and 99407 satisfy the requirement of tobacco cessation intervention, as these services provide tobacco cessation counseling for 3-10 minutes. If a patient received these types of services, submit G-code G9906.

Denominator Exception(s) are determined on the date of the most recent denominator eligible encounter for all submission criteria.

Numerator Options:

Performance Met: Patient identified as a tobacco user received tobacco cessation intervention (counseling and/or pharmacotherapy) (G9906)

OR

Denominator Exception: Documentation of medical reason(s) for not providing tobacco cessation intervention (e.g., limited life expectancy, other medical reason) (G9907)

OR

Performance Not Met: Patient identified as tobacco user did not receive tobacco cessation intervention (counseling and/or pharmacotherapy), reason not given (G9908)

 

Submission Criteria 3: All patients who were screened for tobacco use and, if identified as a tobacco user received tobacco cessation intervention, or identified as a tobacco non-use

Denominator (Submission Criteria 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 NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B PFS. These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years

AND

At least two patient encounters during the performance period (CPT): 90791, 90792, 90832, 90834, 90837, 90845, 92002, 92004, 92012, 92014, 92521, 92522, 92523, 92524, 92540, 92557, 92625, 96156, 96158, 97161, 97162, 97163, 97165, 97166, 97167, 97168, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350

OR

At least one preventive encounter during the performance period (CPT or HCPCS): 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, G0438, G0439

 

Numerator (Submission Criteria 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

Definitions:

Tobacco Use – Includes any type of tobacco.

Tobacco Cessation Intervention – Includes brief counseling (3 minutes or less), and/or pharmacotherapy. Note: For the purpose of this measure, brief counseling (e.g., minimal and intensive advice/counseling interventions conducted both in person and over the phone) qualifies for the numerator. Written self-help materials (e.g., brochures, pamphlets) and complementary/alternative therapies do not qualify for the numerator. Brief counseling also may be of longer duration or be performed more frequently, as evidence shows there is a dose-response relationship between the intensity of counseling provided (either length or frequency) and tobacco cessation rates (U.S. Preventive Services Task Force, 2015).

NUMERATOR NOTE: To satisfy the intent of this measure, a patient must have at least one tobacco use screening during the 12-month period. If a patient has multiple tobacco use screenings during the 12-month period, only the most recent screening, which has a documented status of tobacco user or tobacco non-user, will be used to satisfy the measure requirements.

In the event that a patient is screened for tobacco use and identified as a user but did not receive tobacco cessation intervention or if tobacco status is unknown, submit 4004F with 8P.

If a patient uses any type of tobacco (i.e., smokes or uses smokeless tobacco), the expectation is that they should receive tobacco cessation intervention: either counseling and/or pharmacotherapy.

This measure defines tobacco cessation counseling as lasting 3 minutes or less. Services typically provided under CPT codes 99406 and 99407 satisfy the requirement of tobacco cessation intervention, as these services provide tobacco cessation counseling for 3-10 minutes. If a patient received these types of services, submit CPT II 4004F.

Denominator Exception(s) are determined on the date of the most recent denominator eligible encounter for all submission criteria.

Numerator Options:

Performance Met: Patient screened for tobacco use AND received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user (4004F)

OR

Performance Met: Current tobacco non-user (1036F)

OR

Denominator Exception: Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reason) (4004F with 1P)

OR

Denominator Exception: Documentation of medical reason(s) for not providing tobacco cessation intervention if identified as a tobacco user (e.g., limited life expectancy, other medical reason) (G9909)

OR

Performance Not Met: Tobacco screening not performed OR tobacco cessation intervention not provided, reason not otherwise specified (4004F with 8P)

 

Rationale

This measure is intended to promote adult tobacco screening and tobacco cessation interventions for those who use tobacco products. There is good evidence that tobacco screening and brief cessation intervention (including counseling and/or pharmacotherapy) is successful in helping tobacco users quit. Tobacco users who are able to stop using tobacco lower their risk for heart disease, lung disease, and stroke.

 

Clinical Recommendation Statements

The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA)-approved pharmacotherapy for cessation to adults who use tobacco (Grade A Recommendation) (U.S. Preventive Services Task Force, 2015).

The USPSTF recommends that clinicians ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco (Grade A Recommendation) (U.S. Preventive Services Task Force, 2015).

The USPSTF concludes that the current evidence is insufficient to recommend electronic nicotine delivery systems for tobacco cessation in adults, including pregnant women. The USPSTF recommends that clinicians direct patients who smoke tobacco to other cessation interventions with established effectiveness and safety (previously stated) (Grade I Statement) (U.S. Preventive Services Task Force, 2015).

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