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

Measure Information 2023 Performance Period
CMS Measure ID CMS69v11
NQF Number Not Applicable
Measure Description

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

Denominator Statement

Equals Initial Population

Denominator Exclusions

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 Statement

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

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.

Measure Steward Centers for Medicare & Medicaid Services (CMS)
Quality Domain Community/Population Health
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 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

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.

MIPS Quality ID 128
Meaningful Measure Preventive Care
Telehealth Eligible No
Next Version No Version Available
Previous Version

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Measure Information 2021 Performance Period 2022 Performance Period 2023 Performance Period
CMS Measure ID CMS69v9 CMS69v10 CMS69v11
NQF Number Not Applicable Not Applicable Not Applicable
Measure 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

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

Denominator Statement

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.
Numerator Statement

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

Numerator Exclusions

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.

Measure Steward Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS)
Quality Domain Community/Population Health Community/Population Health Community/Population Health
Measure Scoring Proportion measure Proportion measure Proportion measure
Measure Type Process measure Process measure Process measure
Improvement Notation

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 (https://ecqi.healthit.gov/qdm) 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

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.

MIPS Quality ID 128 128 128
Meaningful Measure Preventive Care Preventive Care Preventive Care
Telehealth Eligible No No No
Next Version CMS69v10 CMS69v11 No Version Available
Previous Version No Version Available

Release Notes

Header

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.

    Measure Section: Guidance

    Source of Change: Standards/Technical Update

  • Revised language by adding timing elements for denominator exclusions for clarification and to better align with measure intent and logic.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Revised wording related to the timing of documentation for BMI and low or high BMI interventions to align with revised logic and to reduce burden on clinicians and implementers.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated grammar, wording, and formatting to improve readability and consistency.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Added 'ascending' to sort expression in the 'BMI during Measurement Period' definition to indicate the sort order and improve clarity.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added the QDM datatype 'Diagnosis' to the logic to allow abnormal BMIs to be captured as diagnoses, providing an alternate way to capture the intent and applicability of the intervention.

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (JIRA): CQM-4602

  • Revised numerator definition to remove unnecessary parentheses to improve readability.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Added Palliative Care Exclusion Library v2.0.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Added Hospice Library v4.0.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Updated logic using the new QDM 5.6 'Encounter, Performed' class attribute to exclude telehealth (or virtual) encounters using the logical representation (class !~ virtual) for measures containing telehealth-eligible codes, where telehealth is not appropriate. For more information, please refer to the 2023 Telehealth Guidance document.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Revised timing for documentation of interventions in 'High BMI and Follow up Provided' and 'Low BMI and Follow up Provided' logic to reduce clinician and implementer burden.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Replaced the 'Patient Has Order for or Receiving Hospice Care or Palliative Care' definition with Hospice and Palliative Care libraries and QDM datatypes to harmonize across measures and reduce clinician and implementer burden.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical 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.

  • Removed direct reference code LOINC code (21112-8) based on 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): Added 17 RxNorm codes based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Medical Reason (2.16.840.1.113883.3.526.3.1007): Deleted 1 SNOMED CT code (397745006) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584): Added 3 SNOMED CT codes (170935008, 170936009, 305911006) based on review by technical experts, SMEs, and/or public feedback. Added 2 CPT codes (99377, 99378) based on review by technical experts, SMEs, and/or public feedback. Added 1 HCPCS code (G0182) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Follow Up for Below Normal BMI (2.16.840.1.113883.3.600.1.1528): Added 1 SNOMED CT code (182922004) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Follow Up for Above Normal BMI (2.16.840.1.113883.3.600.1.1525): Added 1 SNOMED CT code (182922004) based on terminology update. Deleted 1 SNOMED CT code (361231003) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Encounter to Evaluate BMI (2.16.840.1.113883.3.600.1.1751): Added 1 CDT code (D3921) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Removed value set Palliative or Hospice Care (2.16.840.1.113883.3.600.1.1579) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced direct reference code SNOMED CT code (248342006) with value set Underweight (2.16.840.1.113883.3.526.3.1563) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference code ActCode code (VR) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Palliative Care Encounter (2.16.840.1.113883.3.464.1003.101.12.1090) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Hospice Encounter (2.16.840.1.113883.3.464.1003.1003) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Encounter Inpatient (2.16.840.1.113883.3.666.5.307) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference code SNOMED CT code (428371000124100) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference code SNOMED CT code (428361000124107) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference code SNOMED CT code (373066001) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference code LOINC code (71007-9) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference code LOINC code (45755-6) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Medications for Below Normal BMI (2.16.840.1.113883.3.526.3.1562): Added 1 RxNorm code (1928948) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Palliative Care Intervention (2.16.840.1.113883.3.464.1003.198.12.1135) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Pregnancy or Other Related Diagnoses (2.16.840.1.113883.3.600.1.1623): Added 1 SNOMED CT code (417044008) based on terminology update. Deleted 2 SNOMED CT codes (127363001, 44782008) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: May 04, 2022