CMS 69 Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

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Measure Overview

This measure reports the percentage of patients who were 18 years old or older at the beginning of the measurement period who either:

• Had their Body Mass Index (BMI) calculated and it was found to be within the defined parameters, or
• Had their BMI calculated and it was found to be outside the defined parameters. A follow-up plan (or an appropriate prescription) must be documented for these patients.

For this measure, normal BMI parameters are defined as greater than or equal to 18.5 and less than 25.

Telehealth visits will not qualify for this measure. This measure requires the patient's body mass index (BMI) to be calculated. Since BMI calculations require a physical exam, visits with modifiers that indicate telehealth will not qualify.

At a Glance

eMeasure ID	CMS69v8
NQF	0421e
Used For?	Medicaid PI/Stage 3, MIPS (Quality)
Domain	Community/Population Health
MIPS Quality ID	128
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	All patients 18 and older on the date of the encounter with at least one eligible encounter during the measurement period.
Denominator	Initial Patient Population
Numerator	Patients qualify for the numerator if either of the following are true: Their BMI was within the normal range. Their BMI was either too low or too high, and either a follow-up plan (consisting of treatment or a referral for treatment) is made or a medication is prescribed to correct their BMI.

Measure Details

Initial Population/Denominator

Patients are counted in the denominator if they meet both of the following:

• They had at least one non-voided face-to-face encounter during the measurement period. This must be documented in the Plan or E&M section of a Note using a code from the BMI Encounter Code Set Value Set.
• They were 18 years old or older at the beginning of the visit that qualified them for IPP criteria #1. Age is based on the date of birth (DOB) entered on the Information page.

Denominator Exclusions

Patients will be excluded from the denominator if they meet any of the following. Select a link for additional information.

• They were pregnant during the measurement period.
• They received palliative care or had an order for palliative care.
• They refused to have their BMI taken.

When documenting in Past Medical History (PMHx) or the Problem List, a Date of Onset must be entered using the mm/dd/yyyyy format.

Pregnancy

Patients who were pregnant during the measurement period will be excluded from the denominator. This must be documented on the patient’s Problem List using a code from the Pregnancy Dx Value Set. This pregnancy must have been active during the measurement period. It must include an onset date that occurred either before or during the measurement period. If the pregnancy includes a resolved date, the resolved date must occur after the onset date so that the pregnancy was active during the measurement period. Examples (assuming a measurement period that covers 1/1/2020 to 12/31/2020):

• Pregnancy with an onset date of 6/15/2020 and no resolved date. The pregnancy was active during the measurement period and patient will be excluded.
• Pregnancy with an onset date of 11/12/2019 and a resolved date of 08/19/2020. The pregnancy was active during the measurement period and the patient will be excluded.
• Pregnancy with an onset date of 9/13/2019 and a resolved date of 11/19/2019. The pregnancy was not active during the measurement period and the patient will not be excluded.

Palliative Care

Patients who received palliative care or had an order for palliative care will be excluded from the denominator. This can be indicated by either of the following:

• They received Palliative Care prior to or during the most recent visit that qualified them for the denominator. This must be documented in the Assessment section of a Note, Past Medical History (PMHx), Problem List, or with a vocabulary term in the Results or a customized Flowsheet, using a code from the Palliative care encounter Value Set.
• They had an order for palliative or hospice care. This must be documented in the Plan section of a Note using a code from the Palliative or Hospice Care Value Set. This order must have been created prior to or during the most recent visit that qualified them for the denominator.

Patient Refused to Have BMI Taken

Patients who refused to have their BMI taken during the most recent visit that qualified them for the denominator will be excluded. This must be documented using a vocabulary term that represents the Body mass index (BMI) [Ratio] code indicated by the LOINC 39156-5, with select list options indicating codes from the Patient Reason Refused Value Set.

Numerator

For this measure, normal BMI parameters are defined as greater than or equal to 18.5 and less than 25. BMI is calculated using height and weight measurements from the patient’s Vitals.

BMI values displayed on the Facesheet are rounded. These rounded values are not used for measure calculations. The value displayed in the BMI Value field in Results is the number used for calculations.

Patients are counted in the numerator if they meet at least one of the following sets of criteria:

BMI in Normal Range

To be counted in the numerator using this criteria set, the patient’s most recent BMI must have been within the normal range, and must have been recorded during the most recent visit that qualified them for the denominator, or during the 12 months prior to the most recent visit that qualified them for the denominator. This must be documented in Vital Signs or with a vocabulary term in the Results or in a Flowsheet.

BMI Above Normal Range

Patients must meet both of the following to be counted in the numerator using this criteria set:

1.

Their most recent BMI was above the normal range, and was recorded during the most recent visit that qualified them for the denominator, or during the 12 months prior to the most recent visit that qualified them for the denominator. This must be documented in Vital Signs or with a vocabulary term in the Results or in a Flowsheet.

2.

They had at least one of the following:

• A follow-up plan documented during the most recent visit that qualified them for the denominator, or during the 12 months prior to the most recent visit that qualified them for the denominator. This can be documented in either of the following:
  • The Assessment or Plan sections of a Note, using a code from the Above Normal Follow-up Value Set.
  • With a vocabulary term in the Results or in a Flowsheet, using a code from the Referrals where weight assessment may occur Value Set.
• A prescription for an appetite suppressing drug. This prescription must have been written during the most recent visit that qualified them for the denominator, or during the 12 months prior to the most recent visit that qualified them for the denominator. It must be documented in the Plan or Medication List using a value from the Above Normal Medications Value Set.

BMI Below Normal Range

Patients must meet both of the following to be counted in the numerator using this criteria set:

1.

Their most recent BMI was below the normal range, and was recorded during the most recent visit that qualified them for the denominator, or during the 12 months prior to the most recent visit that qualified them for the denominator. This must be documented in Vital Signs or with a vocabulary term in the Results or in a Flowsheet.

2.

They had at least one of the following:

• A follow-up plan documented during the most recent visit that qualified them for the denominator, or during the 12 months prior to the most recent visit that qualified them for the denominator. This can be documented in either of the following:
  • The Assessment or Plan sections of a Note, using a code from the Below Normal Follow up Value Set
  • With a vocabulary term in the Results or in a Flowsheet, using a code from the Referrals where weight assessment may occur Value Set
• A prescription for an appetite stimulating drug. This prescription must have been written during the most recent visit that qualified them for the denominator, or during the 12 months prior to the most recent visit that qualified them for the denominator. It must be documented in the Plan or Medication List using a value from the Below Normal Medication Value Set,

When documenting in Past Medical History (PMHx) or the Problem List, a Date of Onset must be entered using the mm/dd/yyyyy format.

Numerator Exclusions

Not Applicable

Denominator Exception

Patients will be excluded from the denominator if they did not meet the numerator criteria and if either of the following are true:

• Due to a Medical or Other reason, they did not have a follow-up plan for addressing a BMI reading that was either too low or too high. This must be documented in the Results or in a Flowsheet during the most recent visit that qualified them for the denominator, or during the 12 months prior to the most recent visit that qualified them for the denominator. This must be documented using a vocabulary term with a parent code from one of the following Value Sets: Above Normal Follow-Up, Below Normal Follow-Up, or Referrals where weight assessment may occur. This vocabulary term must include a child code from the Medical or Other Reason Note Done Value Set.
• Due to a Medical or Other reason, they were not prescribed medication intended to address a BMI that was either too low or too high. This must be documented in Results or in a Flowsheet during the most recent visit that qualified them for the denominator, or during the 12 months prior to the most recent visit that qualified them for the denominator. This must be documened using a vocabulary term with a parent code from one of the following Value Sets: Above Normal Medications or Below Normal Medications. This vocabulary term must include a child code from the Medical or Other Reason Not Done Value Set.
• Due to a Medial or Other reason, they did not have their BMI taken during the most recent visit that qualified them for the denominator. This must be documented using a vocabulary term that represents the Body mass index (BMI) [Ratio] code indicated by the LOINC 39156-5, with select list options indicating codes from the Medical or Other reason not done Value Set.