2025 MIPS Measure #226

ID: 226

eMeasure ID: CMS138v13

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.

DENOMINATOR:

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

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

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

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.

Examples of PatientLink Screening tools for this measure: