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

General eCQM Information

CMS Measure ID CMS69v9
NQF Number 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

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

Patients receiving palliative or hospice care

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 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

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

* 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.

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

Release Notes

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Removed National Quality Forum (NQF) number, as measure is no longer endorsed.

    Measure Section: NQF Number

    Source of Change: Measure Lead

  • Updated the measure developer field.

    Measure Section: Measure Developer

    Source of Change: Measure Lead

  • Removed endorsed by entity, as measure is no longer endorsed.

    Measure Section: Endorsed By

    Source of Change: Measure Lead

  • Relocated definition for normal BMI parameters from measure description field to the definition field.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated measure language to improve clarity and avoid redundancy.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated disclaimer.

    Measure Section: Disclaimer

    Source of Change: Standards Update

  • Removed clinical recommendation statement related to abnormal blood glucose because this is not relevant to the measure scope and requirements.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Removed clinical recommendation statements related to waist circumference because these are not relevant to the measure scope and requirements.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references to align with American Psychological Association (APA) formatting and removed duplicate reference.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Relocated definition for normal BMI parameters from measure description field to the definition field.

    Measure Section: Definition

    Source of Change: Measure Lead

  • Relocated examples of applicable exceptions from guidance field to denominator exceptions field.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Added text to indicate whether the measure is patient-based or episode-based.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Added text to identify the Quality Data Model (QDM) version used in the measure specification.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Updated measure language to improve clarity and avoid redundancy.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Reclassified patient refusal from denominator exclusion to denominator exception based upon feedback obtained from change review process and supported by the technical expert panel.

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (Jira): CQM-3792

  • Relocated examples of applicable exceptions from guidance field to denominator exceptions field.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

  • Revised denominator exceptions language to more clearly indicate the clinical action to which the denominator exception is applicable. This is intended to provide specificity to aid implementation.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

  • Reclassified patient refusal from denominator exclusion to denominator exception based upon feedback obtained from change review process and supported by the technical expert panel.

    Measure Section: Denominator Exceptions

    Source of Change: ONC Project Tracking System (Jira): CQM-3792

Logic

  • Added hospice care as new data element to the Clinical Quality Language (CQL) definition for palliative and hospice care to align with the measure language, as well as the logic construction used in other measures using similar data elements.

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (Jira): CQM-3172

  • Reclassified patient refusal from denominator exclusion to denominator exception based upon feedback obtained from change review process and supported by the technical expert panel.

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (Jira): CQM-3792

  • Reclassified patient refusal from denominator exclusion to denominator exception based upon feedback obtained from change review process and supported by the technical expert panel.

    Measure Section: Denominator Exceptions

    Source of Change: ONC Project Tracking System (Jira): CQM-3792

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000). Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • 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 Update

  • Updated CQL expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated CQL definition names and aliases used to more closely align with clinical concept intent or create consistency of naming across measures.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Revised CQL definition construction to reduce the overall complexity of the measure logic without changing the intent and/or application of data element. These revisions were intended to make the definition logic less complex, easier to understand, and more meaningful.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Revised measure timings to improve alignment with the intent of the measure requirements.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Value Set

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

  • Replaced value set Underweight (2.16.840.1.113883.3.600.2388) with direct reference code SNOMED CT code (248342006) to align with best practices for replacing single code value sets with direct reference codes.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced RxNorm value set Above Normal Medications (2.16.840.1.113883.3.600.1.1498) with grouping value set Medications for Above Normal BMI (2.16.840.1.113883.3.526.3.1561) to align with best practices, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced RxNorm value set Below Normal Medications (2.16.840.1.113883.3.600.1.1499) with grouping value set Medications for Below Normal BMI (2.16.840.1.113883.3.526.3.1562) to align with best practices, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.600.1.1525): Renamed to Follow Up for Above Normal BMI to align with best practices, based on review by expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.600.1.1527): Renamed to Referrals Where Weight Assessment May Occur to align with best practices, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.600.1.1528): Renamed to Follow Up for Below Normal BMI to align with best practices, based on review by expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.600.1.1623): Renamed to Pregnancy or Other Related Diagnoses to align with best practices, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.600.1.1751): Renamed to Encounter to Evaluate BMI to align with best practices, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Encounter to Evaluate BMI (2.16.840.1.113883.3.600.1.1751): Added 3 CPT codes (96156, 96158, 96159) and deleted 3 CPT codes (96150, 96151, 96152). Deleted 1 SNOMED CT code (32537008) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Follow Up for Below Normal BMI (2.16.840.1.113883.3.600.1.1528): Added 2 HCPCS codes (G0270, G0271) based on terminology update and deleted 7 HCPCS codes (97802, 97803, 97804, 98960, 99078, 99401, 99402). Replaced the 7 deleted HCPCS codes with 7 CPT codes (97802, 97803, 97804, 98960, 99078, 99401, 99402) based on new or changed coding guidelines.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced SNOMED CT value set Hospice Care Ambulatory (2.16.840.1.113762.1.4.1108.15) with grouping value set Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584) to align with best practices, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced value set Medical or Other Reason Not Done (2.16.840.1.113883.3.600.1.1502) with value set Medical Reason (2.16.840.1.113883.3.526.3.1007) for harmonization purposes, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Overweight or Obese (2.16.840.1.113762.1.4.1047.502): Deleted 2 SNOMED CT codes (162690006, 275947003) that do not align with data element intent.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced SNOMED CT value set Patient Reason refused (2.16.840.1.113883.3.600.791) with grouping value set Patient Declined (2.16.840.1.113883.3.526.3.1582) to align with best practices, based on expert review and/or public feedback.

    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 31 SNOMED CT codes and deleted 1 SNOMED CT code (69532007) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Referrals Where Weight Assessment May Occur (2.16.840.1.113883.3.600.1.1527): Deleted 7 SNOMED CT codes (103698003, 103699006, 185359002, 305922005, 410160006, 424203006, 91251008) due to intent of the data element.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced value set Palliative care encounter (2.16.840.1.113883.3.600.1.1575) with direct reference code ICD-10-CM code (Z51.5) to align with best practices for replacing single code value sets with direct reference codes.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Dec 18, 2020