| Measure Information | 2020 Performance Period |
|---|---|
| CMS Measure ID | CMS69v8 |
| 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 |
| Measure Scoring | Proportion measure |
| Measure Type | Process measure |
| 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 < 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. Review the following to apply the Medical Reason exception criteria: 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 |
| MIPS Quality ID | 128 |
| Meaningful Measure | Preventive Care |
| Telehealth Eligible | No |
| Next Version |
Data Element Repository
Header
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Updated eCQM version number.
Measure Section: eCQM Version number
Source of Change: Measure Lead
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Added 'e' to NQF number.
Measure Section: NQF Number
Source of Change: Standards Update
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Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Updated rationale statement to align with recent literature.
Measure Section: Rationale
Source of Change: Expert Work Group Review
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Updated clinical recommendation statement to align with updated clinical guideline.
Measure Section: Clinical Recommendation Statement
Source of Change: Expert Work Group Review
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Updated references to align with American Psychological Association (APA) style.
Measure Section: Reference
Source of Change: Measure Lead
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Updated references.
Measure Section: Reference
Source of Change: Measure Lead
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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
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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
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Updated parenthetical citations to align with American Psychological Association (APA) style.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Logic
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.
Measure Section: Terminology
Source of Change: Annual Update
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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
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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