Patient Assessments

The following should be included as smoking/tobacco products:

• Cigarettes
• Smokeless tobacco (chew, spit, snuff)
• Cigars (cigarillos, little cigars)
• E-cigarettes and vape products
• Dissolvable products (nicotine gel, nicotine pouches, tobacco sticks)
• Hookahs

Do not include marijuana/cannabis products

In order to accurately determine a patient’s smoking status while under the care of the practice, you will need to identify the patient’s smoking status at the first and most recent office visits of the practice being abstracted. Once you have determined the status at the first and most recent office visit, the appropriate option can be selected.

• A never smoker is an adult who has never smoked or has smoked less than 100 cigarettes/cigars/chew tobacco in their lifetime.
• A former smoker is an adult who has smoked at least 100 cigarettes/cigars/chew tobacco in their lifetime but who has quit smoking at the time of interview.
• If the patient is a smoker/tobacco user at their initial office visit and at their most recent office visit, choose “Smoker or tobacco use, while under the care of the practice”
• If the patient was a smoker/tobacco user at their initial office visit and has quit smoking at the time of their last office visit, choose “Smoker or tobacco use, while under the care of the practice AND former smoker”
• If the patient is a former smoker/tobacco user at their initial visit and at their most recent office visit, choose “Former smoker or Tobacco use”
• If the patient is a smoker/tobacco user, quit for a period of time and began smoking/using tobacco again and remained a smoker/tobacco user, choose “smoker or tobacco use while under the care of the practice”
• If the patient has never smoked or used tobacco, choose “Never smoked or used tobacco”

• Smoking cessation/counseling may be provided to the patient by anyone in the oncology practice (MD, NP, PA, RN, MA, Social Worker, Nurse Navigator, etc), but it must be done by the oncology practice in order for it to count (does not include Radiation Oncology). 
• Over-the-counter cessation medicines may include generic forms of these products:
  • Nicorette® (gum or patch)
  • Commit® (lozenge). 
• Prescription cessation medicines may include these products:
  • Chantix®
  • Nicotrol® inhaler, cartridges and nasal spray
  • Zyban® (bupropion)
• Any anti-tobacco pharmacotherapy must either be prescribed or noted by the practice being abstracted to count for this measure.
• Abstractors may only count billing of smoking cessation counseling IF documentation is found in clinic notes.  Billing code alone does not suffice for acceptable cessation documentation.
• If a patient is offered, but declines smoking cessation assistance, this still counts as cessation counseling. Record the date the patient declined assistance.

Some helpful search terms include:

• Power of Attorney
• DPOA
• Advanced Directives
• Five Wishes
• MIPeace of Mind Registry

A living will, release of information (ROI) document, and a do not resuscitate (DNR) order do not qualify for this measure.

Letter of Guardianship Example

Some helpful search terms include:

• Social Drivers of Health
• Social Determinates of Health
• SDOH
• Using search terms for each assessment topic by name (ie: food, housing, transportation, etc)

Non-Medical Needs Assessment Documentation Examples