eCQMs for 2020 Performance Period CMS2v9 CMS22v8 CMS50v8 CMS52v8 CMS56v8 CMS66v8 CMS68v9 CMS69v8 CMS74v9 CMS75v8 CMS82v7 CMS90v9 CMS117v8 CMS122v8 CMS124v8 CMS125v8 CMS127v8 CMS128v8 CMS129v9 CMS130v8 CMS131v8 CMS132v8 CMS133v8 CMS134v8 CMS135v8 CMS136v9 CMS137v8 CMS138v8 CMS139v8 CMS142v8 CMS143v8 CMS144v8 CMS145v8 CMS146v8 CMS147v9 CMS149v8 CMS153v8 CMS154v8 CMS155v8 CMS156v8 CMS157v8 CMS159v8 CMS160v8 CMS161v8 CMS165v8 CMS177v8 CMS249v2 CMS347v3 CMS349v2 CMS645v3 CMS771v1 CMS Measure ID CMS69v8 Version 8 NQF Number 0421e Measure Description Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2 Initial Population All patients 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 Patients receiving palliative or hospice care Patients who refuse measurement of height and/or weight 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 Numerator Exclusions Not Applicable Denominator Exceptions Patients with a documented Medical Reason 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 Measure Steward Centers for Medicare & Medicaid Services (CMS) Domain Community/Population Health Previous Version CMS069v7 Measure Scoring Proportion Measure Type Process Improvement Notation Higher score indicates better quality Guidance * There is no diagnosis associated with this 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 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 The Medical Reason exception could include, but is not limited to, the following patients as deemed appropriate by the health care provider: * Elderly patients (65 or older) for whom weight reduction/weight gain would complicate other underlying health conditions such as the following examples: * Illness or physical disability * Mental illness, dementia, confusion * 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 Quality ID 128 Meaningful Measure Preventive Care Specifications Attachment Size CMS69v8.html 85.5 KB CMS69v8.zip 86.82 KB CMS69v8-TRN.xlsx 22.49 KB Release Notes Header Updated eCQM version number. Measure Section: eCQM Version number Source of Change: Measure Lead Added 'e' to NQF number. Measure Section: NQF Number Source of Change: Standards Update Updated copyright. Measure Section: Copyright Source of Change: Annual Update Updated rationale statement to align with recent literature. Measure Section: Rationale Source of Change: Expert Work Group Review Updated clinical recommendation statement to align with updated clinical guideline. Measure Section: Clinical Recommendation Statement Source of Change: Expert Work Group Review Updated references to align with American Psychological Association (APA) style. Measure Section: Reference Source of Change: Measure Lead Updated references. Measure Section: Reference Source of Change: Measure Lead Updated denominator exclusions statement with removal of follow-up refusal wording to align with logic changes. Measure Section: Denominator Exclusions Source of Change: ONC Project Tracking System (JIRA): CQM-3133 Updated denominator exclusions statement for 'Patients receiving palliative care' to 'Patients receiving palliative or hospice care' to align with the measure intent. Measure Section: Denominator Exclusions Source of Change: ONC Project Tracking System (JIRA): CQM-3023 Updated parenthetical citations to align with American Psychological Association (APA) style. Measure Section: Multiple Sections Source of Change: Measure Lead Logic Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with CQL Style Guide. Measure Section: Definitions and Functions Source of Change: Standards Update Added a 'union' operator of 'Intervention, Performed' for each 'Intervention, Order' for Above and Below Normal Follow-Up Interventions, and a 'union' operator of 'Intervention, Not Performed' for each 'Intervention, Not Ordered' for Above and Below Normal Follow-up Interventions not done due to a medical reason, to meet the measure intent. Measure Section: Multiple Sections Source of Change: ONC Project Tracking System (JIRA): CQM-2903 Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 3 (CQL 1.3). Measure Section: Multiple Sections Source of Change: Standards Update Updated definitions and functions in the Measure Authoring Tool (MAT) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays. Measure Section: Multiple Sections Source of Change: Standards Update Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000). 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 BMI Encounter Code Set (2.16.840.1.113883.3.600.1.1751): Deleted 2 SNOMED CT codes (30346009, 37894004). Added 7 CDT codes (D7111, D7220, D7230, D7240, D7241, D7250, D7251). Measure Section: Terminology Source of Change: Annual Update Value set Below Normal Follow up (2.16.840.1.113883.3.600.1.1528): Added 7 HCPCS codes (97802, 97803, 97804, 98960, 99078, 99401, 99402) and deleted 1 HCPCS code (G8418). Measure Section: Terminology Source of Change: Annual Update Value set Above Normal Follow-Up (2.16.840.1.113883.3.600.1.1525): Added Gastric Procedures CPT extensional value set (2.16.840.1.113762.1.4.1047.515) including 16 codes. Deleted 16 CPT codes from Above Normal f/u CPT extensional value set (2.16.840.1.113883.3.600.1.1524). Measure Section: Terminology Source of Change: Measure Lead Changed the value set name from 'Palliative Care' to 'Palliative or Hospice Care' (2.16.840.1.113883.3.600.1.1579) to align with the measure intent. Measure Section: Terminology Source of Change: ONC Project Tracking System (JIRA): CQM-3023 Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable. Measure Section: Terminology Source of Change: Annual Update Removed code system versions from direct reference codes. Please refer to Appendix A of the Electronic Clinical Quality Measure Logic and Implementation Guidance document for a list of code system versions used in the eCQM specifications for 2020 reporting/performance. Measure Section: Terminology Source of Change: Standards Update Standardized purpose statement language in value sets across eCQMs. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files. Measure Section: Terminology Source of Change: Measure Lead Data Elements contained within CMS069v8 External Resources United States Health Information Knowledgebase NLM Value Set Authority Center (VSAC)