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

General eCQM Information

CMS Measure ID CMS69v10
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 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)
Domain Community/Population Health
Measure Scoring Proportion
Measure Type Process
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

* 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.

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

Release Notes

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

Last Updated: Jul 08, 2021