2023 # 402 Tobacco Use and Help with Quitting Among Adolescents

CMS Measure ID: #402

Collection Type: CQM

Reporting Frequency: Once per patient per year

Outcome: No

High Priority: No

NQS Domain: Community, Population and Public Health

Measure Age: > 2 years

Instructions

This measure is to be submitted 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) Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

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:

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 for registry submissions; however, these codes may be submitted for those registries that utilize claims data.

Description

The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: Yes
Capped at 7: Yes

Decile 0: 0 – 37.83
Decile 1: 37.84 – 84.08
Minimum: 84.09 – 92.4
Decile 3: 92.41 – 96.66
Decile 4: 96.67 – 98.71
Decile 5: 98.72 – 99.64
Decile 6: 99.65 – 99.99
Decile 10: 100 – 100

Denominator

All patients aged 12-20 years with a visit during the measurement period

Denominator Criteria (Eligible Cases):

Patients aged 12-20 years on date of encounter

AND

Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 90845, 92002, 92004, 92012, 92014, 96156, 96158, 97165, 97166, 97167, 97168, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99406, 99407, G0438, G0439

Numerator

Patients who were screened for tobacco use at least once within 18 months (during the measurement period or the six months prior to the measurement period) AND who received tobacco cessation counseling intervention if identified as a tobacco user

Definitions:

Tobacco Use Status – Any documentation of smoking or tobacco use status, including ‘never’ or ‘non-use’.

Tobacco User – Any documentation of active or current use of tobacco products, including smoking.

NUMERATOR NOTE: In the event that a patient is screened for tobacco use and identified as a user but did not receive tobacco cessation counseling, submit G9460.

Numerator Options:

Performance Met:

Patient documented as tobacco user AND received tobacco cessation intervention (must include at least one of the following: advice given to quit smoking or tobacco use, counseling on the benefits of quitting smoking or tobacco use, assistance with or referral to external smoking or tobacco cessation support programs, or current enrollment in smoking or tobacco use cessation program) if identified as a tobacco user (G9458)

Performance Met:

Currently a tobacco non-user (G9459)

Performance Not Met:

Tobacco assessment OR tobacco cessation intervention not performed, reason not given (G9460)