Specifications Manual for Joint Commission National Quality Measures (v2020A1)
Posted: 9/13/2019
Home » Referral for Outpatient Tobacco Cessation Counseling

Release Notes:
Data Element
Version 2020A1

Name:Referral for Outpatient Tobacco Cessation Counseling
Collected For: TOB-3
Definition:Documentation that a referral was made at discharge for ongoing evidence-based counseling with clinicians (physician or non-physician such as nurse, psychologist, counselor). Outpatient counseling may include proactive telephone counseling, group counseling and/or individual counseling. A counseling referral is defined as an appointment made by the healthcare provider or hospital either through telephone contact, fax, the EHR or e-mail. For quitline referrals, the healthcare provider or hospital can either fax or e-mail a quitline referral or assist the patient in directly calling the quitline prior to discharge.
Question:Did the patient receive a referral for Outpatient Tobacco Cessation Counseling?
Allowable Values:

1    The referral to outpatient tobacco cessation counseling treatment was made by the healthcare provider prior to discharge

2    Referral information was given to the patient at discharge but the appointment was not made by the provider prior to discharge

3    The patient refused the referral for outpatient tobacco cessation counseling treatment and the referral was not made

4    The patient:
-is being discharged to a residence outside the USA
-is released to a court hearing and does not return
-is being discharged to jail/law enforcement

5    The referral for outpatient tobacco cessation counseling treatment was not offered at discharge or Unable to Determine (UTD) from the medical record documentation

Notes for Abstraction:
  • If a referral is made to a Quitline, defined as a telephone counseling in which at least some of the contact is initiated by the Quitline counselor to deliver tobacco use interventions, select Value “1.” If the patient directly calls the Quitline during the hospitalization, documentation must reflect that staff was present during the call to verify that an appointment was set.
  • If a patient is referred to an outpatient tobacco cessation counseling provider that does not schedule appointments and the patient was given a specific date and time to present for counseling, select Value “1.”
  • If the patient is provided with contact information for e-health or internet smoking cessation programs which tailor program content to the tobacco user’s needs (by collecting information from the tobacco user and using algorithms to tailor feedback or recommendations, permitting the user to select from various features including extensive information on quitting, tobacco dependence, and related topics) select Value “2.” Note that if Value “2” is selected, the case will not pass the measure. Value “2” can be used as part of an internal performance improvement activity in order to determine if any type of referral was made rather than no referral.
  • If a referral for outpatient tobacco cessation counseling was offered during the hospitalization and the patient refused, select Value “3.” It does not need to be offered again at discharge.
  • If the patient does not have a residence in the USA, Value “4” must be selected.
  • If the patient is provided with self-help materials that are not tailored to the patient’s needs and do not provide a structured program, select Value “5.”
  • Select Value “5” if:
    • it cannot be determined that a referral for outpatient cessation counseling was made or;
    • it is unclear that the absence of the referral was due to a patient refusal or because the referral was not offered.
  • If the patient refused practical counseling (Tobacco Use Treatment Practical Counseling) during the hospitalization, a referral for outpatient tobacco cessation counseling must still be offered at the time of discharge. Select Value “5” if a referral for outpatient counseling was not offered at the time of discharge.
Suggested Data Sources:
  • Discharge summary
  • Transfer sheet
  • Discharge Instruction Sheet
  • Nursing Discharge Notes
  • Physician Order Sheet
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Group counseling
  • Individual counseling
  • Quitline

  • E-health
  • Internet structured programs
  • Self-help interventions in the form of printed/electronic/digital media

Referral for Outpatient Tobacco Cessation Counseling
CPT® only copyright 2019 American Medical Association. All rights reserved.
Specifications Manual for Joint Commission National Quality Measures (v2020A1)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)


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