CMS Measure ID: #402
Collection Type: CQM
Reporting Frequency: Once per patient per year
High Priority: No
NQS Domain: Community, Population and Public Health
Measure Age: > 2 years
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.
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)
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
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
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
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
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.
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)
Currently a tobacco non-user (G9459)
Performance Not Met:
Tobacco assessment OR tobacco cessation intervention not performed, reason not given (G9460)