Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

Measure Information	2022 Performance Period
CMS eCQM ID	CMS69v10
NQF Number	Not Applicable
MIPS Quality ID	128
Description	Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if most recent BMI was outside of normal parameters
Initial Population	All patients aged 18 and older on the date of the encounter with at least one eligible encounter during the measurement period
Numerator	Patients with a documented BMI during the encounter or during the previous twelve months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter
Numerator Exclusions	Not Applicable
Denominator	Equals Initial Population
Denominator Exclusions	Patients who are pregnant Patients receiving palliative or hospice care
Denominator Exceptions	Patients with a documented medical reason for not documenting BMI or for not documenting a follow-up plan for a BMI outside normal parameters (e.g., elderly patients 65 years of age or older for whom weight reduction/weight gain would complicate other underlying health conditions such as illness or physical disability, mental illness, dementia, confusion, or nutritional deficiency such as vitamin/mineral deficiency; patients in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status) Patients who refuse measurement of height and/or weight
Steward	Centers for Medicare & Medicaid Services (CMS)
Measure Scoring	Proportion measure
Measure Type	Process measure
Improvement Notation	Higher score indicates better quality
Guidance	BMI Measurement Guidance: * Height and Weight - An eligible professional or their staff is required to measure both height and weight. Both height and weight must be measured within twelve months of the current encounter and may be obtained from separate encounters. Self-reported values cannot be used. * The BMI may be documented in the medical record of the provider or in outside medical records obtained by the provider. * If the most recent documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter. * If more than one BMI is reported during the measurement period, the most recent BMI will be used to determine if the performance has been met. * Review the exclusions and exceptions criteria to determine those patients that BMI measurement may not be appropriate or necessary. Follow-Up Plan Guidance: * The documented follow-up plan must be based on the most recent documented BMI, outside of normal parameters, example: "Patient referred to nutrition counseling for BMI above or below normal parameters." (See Definitions for examples of follow-up plan treatments). Variation has been noted in studies exploring optimal BMI ranges for the elderly (see Donini et al., [2012]; Holme & Tonstad [2015]; Diehr et al. [2008]). Notably however, all these studies have arrived at ranges that differ from the standard range for ages 18 and older, which is >=18.5 and < 25 kg/m2. For instance, both Donini et al. (2012) and Holme and Tonstad (2015) reported findings that suggest that higher BMI (higher than the upper end of 25kg/m2) in the elderly may be beneficial. Similarly, worse outcomes have been associated with being underweight (at a threshold higher than 18.5 kg/m2) at age 65 (Diehr et al. 2008). Because of optimal BMI range variation recommendations from these studies, no specific optimal BMI range for the elderly is used. However, it may be appropriate to exempt certain patients from a follow-up plan by applying the exception criteria. See denominator exception section for examples. * This eCQM is a patient-based measure. This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. * This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided at the time of the qualifying encounter and the measure-specific denominator coding. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.
Telehealth Eligible	No
Next Version	CMS69v11
Previous Version	CMS69v9

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Measure Information	2021 Performance Period	2022 Performance Period	2023 Performance Period	2024 Performance Period
Title	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
CMS eCQM ID	CMS69v9	CMS69v10	CMS69v11	CMS69v12
NQF Number	Not Applicable	Not Applicable	Not Applicable	Not Applicable
Description	Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if most recent BMI was outside of normal parameters	Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if most recent BMI was outside of normal parameters	Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the measurement period AND who had a follow-up plan documented if BMI was outside of normal parameters	Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the measurement period AND who had a follow-up plan documented if BMI was outside of normal parameters
Initial Population	All patients aged 18 and older on the date of the encounter with at least one eligible encounter during the measurement period	All patients aged 18 and older on the date of the encounter with at least one eligible encounter during the measurement period	All patients aged 18 and older on the date of the encounter with at least one eligible encounter during the measurement period	All patients aged 18 and older on the date of the encounter with at least one qualifying encounter during the measurement period
Denominator	Equals Initial Population	Equals Initial Population	Equals Initial Population	Equals Initial Population
Denominator Exclusions	Patients who are pregnant Patients receiving palliative or hospice care	Patients who are pregnant Patients receiving palliative or hospice care	Patients who are pregnant at any time during the measurement period. Patients receiving palliative or hospice care at any time during the measurement period.	Patients who are pregnant at any time during the measurement period.Patients receiving palliative or hospice care at any time during the measurement period.
Numerator	Patients with a documented BMI during the encounter or during the previous twelve months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter	Patients with a documented BMI during the encounter or during the previous twelve months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter	Patients with a documented BMI during the encounter or during the measurement period, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the measurement period	Patients with a documented BMI during the encounter or during the measurement period, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the measurement period
Numerator Exclusions	Not Applicable	Not Applicable	Not Applicable	Not Applicable
Denominator Exceptions	Patients with a documented medical reason for not documenting BMI or for not documenting a follow-up plan for a BMI outside normal parameters (e.g., elderly patients (65 or older) for whom weight reduction/weight gain would complicate other underlying health conditions such as illness or physical disability, mental illness, dementia, confusion, or nutritional deficiency such as vitamin/mineral deficiency; patients in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status) Patients who refuse measurement of height and/or weight	Patients with a documented medical reason for not documenting BMI or for not documenting a follow-up plan for a BMI outside normal parameters (e.g., elderly patients 65 years of age or older for whom weight reduction/weight gain would complicate other underlying health conditions such as illness or physical disability, mental illness, dementia, confusion, or nutritional deficiency such as vitamin/mineral deficiency; patients in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status) Patients who refuse measurement of height and/or weight	Patients with a documented medical reason for not documenting BMI or for not documenting a follow-up plan for a BMI outside normal parameters (e.g., elderly patients 65 years of age or older for whom weight reduction/weight gain would complicate other underlying health conditions such as illness or physical disability, mental illness, dementia, confusion, or nutritional deficiency such as vitamin/mineral deficiency; patients in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status). Patients who refuse measurement of height and/or weight.	Patients with a documented medical reason for not documenting BMI or for not documenting a follow-up plan for a BMI outside normal parameters (e.g., elderly patients 65 years of age or older for whom weight reduction/weight gain would complicate other underlying health conditions such as illness or physical disability, mental illness, dementia, confusion, or nutritional deficiency such as vitamin/mineral deficiency; patients in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status). Patients who refuse measurement of height and/or weight.
Measure Steward	Centers for Medicare & Medicaid Services (CMS)	Centers for Medicare & Medicaid Services (CMS)	Centers for Medicare & Medicaid Services (CMS)	Centers for Medicare & Medicaid Services (CMS)
Measure Scoring	Proportion measure	Proportion measure	Proportion measure	Proportion measure
Measure Type	Process measure	Process measure	Process measure	Process measure
Improvement Notation	Higher score indicates better quality	Higher score indicates better quality	Higher score indicates better quality	Higher score indicates better quality
Guidance	* This eCQM is a patient-based measure. This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. * There is no diagnosis associated with this measure. * This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided at the time of the qualifying visit and the measure-specific denominator coding. BMI Measurement Guidance: * Height and Weight - An eligible professional or their staff is required to measure both height and weight. Both height and weight must be measured within twelve months of the current encounter and may be obtained from separate encounters. Self-reported values cannot be used. * The BMI may be documented in the medical record of the provider or in outside medical records obtained by the provider. * If the most recent documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter. * If more than one BMI is reported during the measurement period, the most recent BMI will be used to determine if the performance has been met. * Review the exclusions and exceptions criteria to determine those patients that BMI measurement may not be appropriate or necessary. Follow-Up Plan Guidance: * The documented follow-up plan must be based on the most recent documented BMI, outside of normal parameters, example: "Patient referred to nutrition counseling for BMI above or below normal parameters." (See Definitions for examples of follow-up plan treatments). Variation has been noted in studies exploring optimal BMI ranges for the elderly (see Donini et al., [2012]; Holme & Tonstad [2015]; Diehr et al. [2008]). Notably however, all these studies have arrived at ranges that differ from the standard range for ages 18 and older, which is >=18.5 and < 25 kg/m2. For instance, both Donini et al. (2012) and Holme and Tonstad (2015) reported findings that suggest that higher BMI (higher than the upper end of 25kg/m2) in the elderly may be beneficial. Similarly, worse outcomes have been associated with being underweight (at a threshold higher than 18.5 kg/m2) at age 65 (Diehr et al. 2008). Because of optimal BMI range variation recommendations from these studies, no specific optimal BMI range for the elderly is used. However, it may be appropriate to exempt certain patients from a follow-up plan by applying the exception criteria. See denominator exception section for examples. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.	BMI Measurement Guidance: * Height and Weight - An eligible professional or their staff is required to measure both height and weight. Both height and weight must be measured within twelve months of the current encounter and may be obtained from separate encounters. Self-reported values cannot be used. * The BMI may be documented in the medical record of the provider or in outside medical records obtained by the provider. * If the most recent documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter. * If more than one BMI is reported during the measurement period, the most recent BMI will be used to determine if the performance has been met. * Review the exclusions and exceptions criteria to determine those patients that BMI measurement may not be appropriate or necessary. Follow-Up Plan Guidance: * The documented follow-up plan must be based on the most recent documented BMI, outside of normal parameters, example: "Patient referred to nutrition counseling for BMI above or below normal parameters." (See Definitions for examples of follow-up plan treatments). Variation has been noted in studies exploring optimal BMI ranges for the elderly (see Donini et al., [2012]; Holme & Tonstad [2015]; Diehr et al. [2008]). Notably however, all these studies have arrived at ranges that differ from the standard range for ages 18 and older, which is >=18.5 and < 25 kg/m2. For instance, both Donini et al. (2012) and Holme and Tonstad (2015) reported findings that suggest that higher BMI (higher than the upper end of 25kg/m2) in the elderly may be beneficial. Similarly, worse outcomes have been associated with being underweight (at a threshold higher than 18.5 kg/m2) at age 65 (Diehr et al. 2008). Because of optimal BMI range variation recommendations from these studies, no specific optimal BMI range for the elderly is used. However, it may be appropriate to exempt certain patients from a follow-up plan by applying the exception criteria. See denominator exception section for examples. * This eCQM is a patient-based measure. This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. * This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided at the time of the qualifying encounter and the measure-specific denominator coding. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.	BMI Measurement Guidance: * Height and Weight - An eligible professional or their staff is required to measure both height and weight. Both height and weight must be measured during the measurement period. Self-reported values cannot be used. * The BMI may be documented in the medical record of the provider or in outside medical records obtained by the provider. * If the documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the measurement period. * If more than one BMI is reported during the measurement period, and any of the documented BMI assessments is outside of normal parameters, documentation of an appropriate follow-up plan will be used to determine if performance has been met. * Review the exclusions and exceptions criteria to determine those patients that BMI measurement may not be appropriate or necessary. Follow-Up Plan Guidance: * The documented follow-up plan must be based on the documented BMI, outside of normal parameters, example: "Patient referred to nutrition counseling for BMI above or below normal parameters." See the Definition section for examples of follow-up plan treatments. Variation has been noted in studies exploring optimal BMI ranges for the elderly (see Donini et al., [2012]; Holme & Tonstad [2015]; Diehr et al. [2008]). Notably however, all these studies have arrived at ranges that differ from the standard range for ages 18 and older, which is >=18.5 and < 25 kg/m2. For instance, both Donini et al. (2012) and Holme and Tonstad (2015) reported findings that suggest that higher BMI (higher than the upper end of 25kg/m2) in the elderly may be beneficial. Similarly, worse outcomes have been associated with being underweight (at a threshold higher than 18.5 kg/m2) at age 65 (Diehr et al. 2008). Because of optimal BMI range variation recommendations from these studies, no specific optimal BMI range for the elderly is used. However, it may be appropriate to exempt certain patients from a follow-up plan by applying the exception criteria. See Denominator Exception section for examples. This eCQM is a patient-based measure. This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided at the time of the qualifying encounter and the measure-specific denominator coding. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.	BMI Measurement Guidance: - Height and Weight - An eligible professional or their staff is required to measure both height and weight. Both height and weight must be measured during the measurement period. Self-reported values cannot be used. - The BMI may be documented in the medical record of the provider or in outside medical records obtained by the provider. - If the documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the measurement period. - If more than one BMI is reported during the measurement period, and any of the documented BMI assessments is outside of normal parameters, documentation of an appropriate follow-up plan will be used to determine if performance has been met. - Review the exclusions and exceptions criteria to determine those patients that BMI measurement may not be appropriate or necessary. Follow-Up Plan Guidance: The documented follow-up plan must be based on the documented BMI, outside of normal parameters, example: "Patient referred to nutrition counseling for BMI above or below normal parameters." See the Definition section for examples of follow-up plan treatments. Variation has been noted in studies exploring optimal BMI ranges for the elderly (see Donini et al., 2012; Holme & Tonstad, 2015; Diehr et al., 2008). Notably however, all these studies have arrived at ranges that differ from the standard range for ages 18 and older, which is >= 18.5 and < 25 kg/m2. For instance, both Donini et al. and Holme and Tonstad reported findings that suggest that higher BMI (higher than the upper end of 25 kg/m2) in the elderly may be beneficial. Similarly, worse outcomes have been associated with being underweight (at a threshold higher than 18.5 kg/m2) at age 65 (Diehr et al., 2008). Because of optimal BMI range variation recommendations from these studies, no specific optimal BMI range for the elderly is used. However, it may be appropriate to exempt certain patients from a follow-up plan by applying the exception criteria. See Denominator Exception section for examples. This eCQM is a patient-based measure. This measure is to be reported a minimum of once per measurement period for patients seen during the measurement period. This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided at the time of the qualifying encounter and the measure-specific denominator coding. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.
MIPS Quality ID	128	128	128	128
Telehealth Eligible	No	No	No	No
Next Version	CMS69v10	CMS69v11	CMS69v12	No Version Available
Previous Version	No Version Available	CMS69v9	CMS69v10	CMS69v11

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Data Elements contained within CMS69v10

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Value Sets to be used with CMS69v10

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CMS69v10-TRN.xlsx

Header

Updated the eCQM version number.

Measure Section: eCQM Version Number

Source of Change: Annual Update
Updated Measure Developer.

Measure Section: Measure Developer

Source of Change: Measure Lead
Updated copyright.

Measure Section: Copyright

Source of Change: Annual Update
Updated disclaimer.

Measure Section: Disclaimer

Source of Change: Annual Update
Updated the rationale to align with current evidence based on published literature.

Measure Section: Rationale

Source of Change: Measure Lead
Updated references.

Measure Section: Reference

Source of Change: Annual Update
Removed 'There is no diagnosis associated with this measure' from the guidance section to ensure that the measure guidance aligns with eCQM technical specification and logic, which does use diagnosis codes.

Measure Section: Guidance

Source of Change: Annual Update
Added clarifying language to guidance section indicating that the measure is not eligible for telehealth visits.

Measure Section: Guidance

Source of Change: Measure Lead
Made minor updates to grammar and wording to improve readability and consistency.

Measure Section: Multiple Sections

Source of Change: Annual Update

Logic

Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

Measure Section: Multiple Sections

Source of Change: Standards Update
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.

Measure Section: Multiple Sections

Source of Change: Standards Update
Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.

Measure Section: Multiple Sections

Source of Change: Standards Update

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

Value set Encounter to Evaluate BMI (2.16.840.1.113883.3.600.1.1751): Deleted 1 CPT code (99201) based on terminology update.

Measure Section: Terminology

Source of Change: Annual Update
Value set Pregnancy or Other Related Diagnoses (2.16.840.1.113883.3.600.1.1623): Added 5 ICD-10-CM codes (O99.891, O99.892, O99.893, 034.218, 034.22), Deleted 2 ICD-10-CM codes (A34, O99.89), Added 1 SNOMED CT code (169488004), Deleted 1 SNOMED CT code (102873005) based on terminology update and review by technical experts, SMEs, and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Medications for Above Normal BMI (2.16.840.1.113883.3.526.3.1561): Deleted 2 RxNorm codes (1300706, 1808549) based on terminology update.

Measure Section: Terminology

Source of Change: Annual Update
Value set Medications for Below Normal BMI (2.16.840.1.113883.3.526.3.1562): Deleted 1 RxNorm code (860231) based on terminology update.

Measure Section: Terminology

Source of Change: Annual Update