This composite measure contains 7 component measures that were previously specified as individual quality measures. After assessing the issue, CMS determined that there are incorrect instructions within the measure specification regarding Submission Criteria #6 (quality measure #2261 component) that require the reporting of all 3 performance rates. Rather than submitting all 3 performance rates for Submission Criteria #6 (quality measure #2261 component), only the 2nd performance rate (identified as Submission Criteria #6b within the measure specification)will be required when reporting this component measure within the composite measure for the 2024 performance period. There aren't any issues regarding the other 6 component measures for this composite measure.
Reporting the Measure
All 7 component measures and applicable Submission Criteria are required for reporting this composite measure. To report Submission Criteria #6 (quality measure #2261component), you'll onlysubmit the 2ndperformance rate (Submission Criteria #6b) as documented in the QPP measures repository on GitHub shown below:
Submission Criteria #6b "tobacco": Percentage of patients screened for tobacco use and, if identified as a tobacco user, received cessation intervention during the encounter or within the previous 6 months.
Next Steps
CMS won't update the measure's specifications. However, CMS will:
Provide more information in upcoming Qualified Clinical Data Registry (QCDR) and Quality Registry Support Calls.
On October 7, the Centers for Medicare & Medicaid Services (CMS) updated its Quality Payment Program Participation Status Tool based on the second snapshot of Alternative Payment Model (APM) data. The second snapshot includes data from Medicare Part B claims with dates of service between January 1, 2024, and June 30, 2024.
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