2024 MIPS Measure #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

2024 COLLECTION TYPE:

MIPS Clinical Quality Measures (CQMS)

‌MEASURE TYPE: Process

Description

‌Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within 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.

‌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.

This measure will be calculated with 3 performance rates:

1. Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period
2. 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
3. Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within 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

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 (including but not limited to encounters coded with GQ, GT, 95, POS 02, POS 10) 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 during the measurement period and who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period

   AND

3. All patients who were screened for tobacco use and, if identified as a tobacco user received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period, 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 during the measurement period and who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period (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. For the purposes of submitting this measure, use the data completeness determined in Submission Criteria 1.

Submission Criteria 1:

All patients who were screened for tobacco use

‌Denominator (Submission Criteria 1):

All patients aged 12 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 ≥ 12 years on date of encounter

AND

At least two patient encounters during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90845, 92002, 92004, 92012, 92014, 92521, 92522, 92523, 92524, 92540, 92557, 92622, 92625, 96156, 96158, 97161, 97162, 97163, 97165, 97166, 97167, 97168, 97802, 97803, 97804, 98980, 99024, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99421, 99422, 99423, 99457, G0270, G0271, G2250, G2251, G2252

OR

At least one preventive encounter during the performance period (CPT or HCPCS): 99384*, 99385*, 99386*, 99387*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, G0438, G0439

AND NOT

Denominator Exclusion:

Hospice services provided to patient any time during the measurement period: M1159

Numerator (Submission Criteria 1)

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

Definition:

Tobacco Use – use of any tobacco product

The 2021 USPSTF recommendation references the US Food and Drug Administration definition of tobacco which includes “any product made or derived from tobacco intended for human consumption (except products that meet the definition of drugs), including, but not limited to, cigarettes, cigars (including cigarillos and little cigars), dissolvables, hookah tobacco, nicotine gels, pipe tobacco, roll-your-own tobacco, smokeless tobacco products (including dip, snuff, snus, and chewing tobacco), vapes, electronic cigarettes (e-cigarettes), hookah pens, and other electronic nicotine delivery systems.”

The 2021 USPSTF recommendation describes smoking as generally referring to “the inhaling and exhaling of smoke produced by combustible tobacco products such as cigarettes, cigars, and pipes.”

The 2021 USPSTF recommendation describes vaping as “the inhaling and exhaling of aerosols produced by e-cigarettes.” In addition, it states, “vaping products (i.e., e-cigarettes) usually contain nicotine, which is the addictive ingredient in tobacco. Substances other than tobacco can also be used to smoke or vape.

While the 2015 USPSTF recommendation statement used the term ‘electronic nicotine delivery systems’ or ‘ENDS,’ the USPSTF recognizes that the field has shifted to using the term ‘e-cigarettes’ (or ‘e-cigs’) and uses the term e-cigarettes in the current recommendation statement. e-Cigarettes can come in many shapes and sizes, but generally they heat a liquid that contains nicotine (the addictive drug in tobacco) to produce an aerosol (or ‘vapor’) that is inhaled (‘vaped’) by users.”

NUMERATOR NOTE: To satisfy the intent of this measure, a patient must have at least one tobacco use screening during the measurement period. If a patient has multiple tobacco use screenings during the measurement 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.

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

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

Submission Criteria 2

All patients who were identified as a tobacco user and who recieved tobacco cessation intervention.

Denominator (Submission Criteria 2):

All patients aged 12 years and older seen for at least two visits or at least one preventive visit who were screened for tobacco use during the measurement period 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 ≥ 12 years on date of encounter

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, 92622, 92625, 96156, 96158, 97161, 97162, 97163, 97165, 97166, 97167, 97168, 97802, 97803, 97804, 98980, 99024, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99421, 99422, 99423, 99457, G0270, G0271, G2250, G2251, G2252

OR

At least one preventive encounter during the performance period (CPT or HCPCS): 99384*, 99385*, 99386*, 99387*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, G0438, G0439

AND NOT

Denominator Exclusion:

Hospice services provided to patient any time during the measurement period: M1159

‌Numerator (Submission Criteria 2):

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

Definition:

Tobacco Cessation Intervention – Includes brief counseling (3 minutes or less), and/or pharmacotherapy.

Note: Concepts aligned with brief counseling (e.g., minimal and intensive advice/counseling interventions conducted both in person and over the phone) are included in the numerator. Other concepts such as written self-help materials (e.g., brochures, pamphlets) and complementary/alternative therapies do not qualify for the numerator. Counseling also may be of longer duration or be performed more frequently, as evidence shows that higher-intensity interventions are associated with higher tobacco cessation rates (U.S. Preventive Services Task Force, 2021).

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.

Numerator Options:

Performance Met: Patient identified as a tobacco user received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period (counseling and/or pharmacotherapy) (G9906)

OR

Performance Not Met: Patient identified as tobacco user did not receive tobacco cessation intervention during the measurement period or in the six months prior to the measurement period (counseling and/or pharmacotherapy) (G9908)

Submission Criteria 3

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

‌Denominator (Submission Criteria 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 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 ≥ 12 years on date of encounter

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, 92622, 92625, 96156, 96158, 97161, 97162, 97163, 97165, 97166, 97167, 97168, 97802, 97803, 97804, 98980, 99024, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99421, 99422, 99423, 99457, G0270, G0271, G2250, G2251, G2252

OR

At least one preventive encounter during the performance period (CPT or HCPCS): 99384*, 99385*, 99386*, 99387*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, G0438, G0439

AND NOT

Denominator Exclusion

‌Hospice services provided to patient any time during the measurement period: M1159

Numerator (Submission Criteria 3)

Patients who were screened for tobacco use at least once within 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

Definitions:

Tobacco Use – use of any tobacco product.

The 2021 USPSTF recommendation references the US Food and Drug Administration definition of tobacco which includes “any product made or derived from tobacco intended for human consumption (except products that meet the definition of drugs), including, but not limited to, cigarettes, cigars (including cigarillos and little cigars), dissolvables, hookah tobacco, nicotine gels, pipe tobacco, roll-your-own tobacco, smokeless tobacco products (including dip, snuff, snus, and chewing tobacco), vapes, electronic cigarettes (e-cigarettes), hookah pens, and other electronic nicotine delivery systems.”

The 2021 USPSTF recommendation describes smoking as generally referring to “the inhaling and exhaling of smoke produced by combustible tobacco products such as cigarettes, cigars, and pipes.”

The 2021 USPSTF recommendation describes vaping as “the inhaling and exhaling of aerosols produced by e-cigarettes.” In addition, it states, “vaping products (i.e., e-cigarettes) usually contain nicotine, which is the addictive ingredient in tobacco. Substances other than tobacco can also be used to smoke or vape.

While the 2015 USPSTF recommendation statement used the term ‘electronic nicotine delivery systems’ or ‘ENDS,’ the USPSTF recognizes that the field has shifted to using the term ‘e-cigarettes’ (or ‘e-cigs’) and uses the term e-cigarettes in the current recommendation statement. e-Cigarettes can come in many shapes and sizes, but generally they heat a liquid that contains nicotine (the addictive drug in tobacco) to produce an aerosol (or ‘vapor’) that is inhaled (‘vaped’) by users.”

Tobacco Cessation Intervention – Includes brief counseling (3 minutes or less), and/or pharmacotherapy.

Note: Concepts aligned with brief counseling (e.g., minimal and intensive advice/counseling interventions conducted both in person and over the phone) are included in the numerator. Other concepts such as written self-help materials (e.g., brochures, pamphlets) and complementary/alternative therapies do not qualify for the numerator. Counseling also may be of longer duration or be performed more frequently, as evidence shows that higher-intensity interventions are associated with higher tobacco cessation rates (U.S. Preventive Services Task Force, 2021).

NUMERATOR NOTE: To satisfy the intent of this measure, a patient must have at least one tobacco use screening during the measurement period. If a patient has multiple tobacco use screenings during the measurement 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 during the measurement period or in the six months prior to the measurement period or if tobacco status is unknown, submit G0029.

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 G0030.

Numerator Options:

Performance Met: Patient screened for tobacco use AND received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period (counseling, pharmacotherapy, or both), if identified as a tobacco user (G0030)

OR

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

OR

‌Performance Not Met: Tobacco screening not performed OR tobacco cessation intervention not provided during the measurement period or in the six months prior to the measurement period (G0029)