CMS 155 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents

Greenway Health's Regulatory Resource Hub provides a single-access point for information about regulatory reporting.

Click the following dropdown to see what's new for this measure in 2020.

Overview

This measure reports the percentage of patients 3-17 years old who had their BMI percentile documented. Qualifying patients must have received counseling for nutrition and physical activity.

Prime Suite Reporting reports each of this measure’s three populations individually, using the same Initial Patient Population, Denominator, and Denominator Exclusion criteria:

For Rate #1, choose CMS 155 (BMI).
For Rate #2, choose CMS 155 (Nutritional Counseling).
For Rate #3, choose CMS 155 (Physical Activity).

At a Glance

eMeasure ID	CMS155v8
NQF	0024
Used For?	Medicaid PI/Stage 3, MIPS (Quality)
Domain	Community/Population Health
MIPS Quality ID	239
MIPS Measure Type	Process
MIPS High Priority?	No

Measure Specification and Value Sets

You should be familiar with this measure’s specification, Value Sets, and direct reference codes (if applicable). Refer to Downloading Measure Specifications and Value Sets for more information. Measure help now includes hyperlinks to the Value Sets used by this measure. You must be registered for a UMLS license and signed in to your account to see this content.

Identifying Event Times

See Identifying Event Times for important information about the logic this dashboard uses.

Amending Signed Notes

As a best practice, Notes should not be signed until they are finalized. Amending a signed Note (by making changes to it in Prime Suite and then re-saving it) will change a patient’s qualification for this measure. Re-signing the amended Note may allow the patient to qualify again, but only if it is re-signed during the time period required by the measure.

Measure Calculations

Initial Population	Patients 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or an obstetrician/gynecologist (OB/GYN) during the measurement period
Denominator	Initial Patient Population
Rate 1:	Patients who had a height, weight, and body mass index (BMI) percentile recorded during the measurement period.
Rate 2:	Patients who had counseling for nutrition during a visit that occurs during the measurement period.
Rate 3:	Patients who had counseling for physical activity during a visit that occurs during the measurement period.

Rate Stratification

To qualify, patients must be at least 3 years old, but no older than 16 years old, at the beginning of the reporting period. Patients who turn 17 years old after the first day of the reporting period will qualify. Patients who turn 18 years old during the reporting period will not qualify.

The following age stratifications are reported:

Stratum 1:	Patients 3-11 years of age at the start of the measurement period
Stratum 2:	Patients 12-17 years of age at the start of the measurement period

Measure Details

Initial Population/Denominator

Patients are counted in the denominator if both of the following are met:

They were 3 to 16 years old at the beginning of the measurement period. Patients who turned 17 years old on the second day of the measurement period will qualify. Patients who turned 18 years old during the measurement period will not qualify. Age is based on the date of birth (DOB) entered on the patient’s Information page.
They had at least one face-to-face visit documented in the Plan or E&M section of a note during the measurement period. This documentation must be use a code from one of the following Value Sets:

Denominator Exclusions

Encounters will be excluded from the denominator if they involved patients who meet any of the following. Select a link for additional information.

They received hospice care.
They had a pregnancy diagnosis.

Hospice Care

Patients will be excluded from the denominator if they received hospice care. This must be documented with a vocabulary term in the Results or in a Flowsheet. This documentation must show one of the following:

They were discharged from the hospital into hospice care during the measurement period. This must be documented with a vocabulary term using a parent code from the Encounter Inpatient Value Set and a child code using either of the following SNOMEDCT version 2019-05-10 direct reference codes:
- 428371000124100, indicating a patient was Discharged to a health care facility for hospice care.
- 428361000124107, indicating a patient was Discharged to home for hospice care.
They received hospice care. This must be documented with a vocabulary term in a Flowsheet using a code from the Hospice care ambulatory Value Set. The date the provider enters this documentation must occur during the measurement period.
They had an order for hospice care. This must be documented in the Plan or Results section of a Note using a code from the Hospice care ambulatory Value Set. This order must have been created during the measurement period.

Pregnancy

A diagnosis of pregnancy must be indicated on the patient’s Problem List. This problem must be documented using a code from the Pregnancy Value Set. It must have been active during the measurement period, with a date of onset that occurred before or during the measurement period. If this pregnancy has been marked as Resolved, its resolved date must occur during the measurement period, but after the date of onset.

Examples (assuming a measurement period that covers 1/1/2017 to 12/31/2017):

Pregnancy with an date of onset of 6/15/2017 and no resolved date. The pregnancy was active during the measurement period and the patient will be excluded.
Pregnancy with an date of onset of 11/12/2016 and a resolved date of 08/19/2017. The pregnancy was active during the measurement period and the patient will be excluded.
Pregnancy with an date of onset of 12/18/2017 and a resolved date of 09/08/2018. The pregnancy was active during the measurement period and the patient will be excluded.
Pregnancy with an onset date of 9/13/2016 and a resolved date of 11/19/2016. The pregnancy was not active during the measurement period and the patient will not be excluded.

When documenting on the Problem List, a Date of Onset must be entered using the mm/dd/yyyyy format.

Numerator

Patients are counted in the numerator if they meet any of the following:

Rate #1

Rate #1 counts patients who had their height, weight, and BMI percentile recorded during the measurement period. These values must be documented in Vital Signs or with a vocabulary term in the Results or on a Flowsheet. The vocabulary term used when documenting each of these values must be mapped to a code from the proper Value Set: Height, Weight, and BMI percentile.

Rate #2

Rate #2 counts patients who received nutritional counseling during the measurement period. This must be documented using a code from the Counseling for Nutrition Value Set. Be aware that the codes 97802, 97803, and 97804 have different documentation requirements than the other codes from this value set.

97802, 97803, and 97804 must be documented in the E&M or Plan section of a clinical note. If documented in the Plan section of the clinical note, you must also set a status of Returned or Reviewed. The status can be set before saving the Plan section or through Orders Tracking History.
All other codes from the value set must be documented in Orders Tracking History (with a status of Returned or Reviewed) or with a vocabulary term in the Results or in a Flowsheet.

Rate #3

Rate #3 counts patients who received counseling for physical activity during the measurement period. This must be documented with a vocabulary term in the Results or in a Flowsheet during the measurement period. This documentation must use a code from the Counseling for Physical Activity Value Set.

Numerator Exclusions

Not Applicable

Denominator Exception

None