CMS 69 - Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Plan

Overview

CMS69v8 (2020)
CMS69v9 (2021)
CMS69v10 (2022)

Identifiers

CMS eCQM ID	NQF eCQM ID	NQF	MIPS Quality ID
CMS69v10	–	–	128

*MIE only supports data collection and reporting using eCQM specifications

Definitions

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 Patient Population	All patients aged 18 and older on the date of the encounter with at least one eligible encounter during the measurement period.
Denominator	Equals Initial Population
Denominator Exclusions	Patients who are pregnant Patients receiving palliative or hospice care
Numerator	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	–
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

Additional Information

Measure Type	Process measure
Measure Scoring	Proportion measure
Granularity	Patient
Improvement Notation	Higher score indicates better quality
Domain	Community/Population Health

Clinical Instructions

Track all 18+ year-old patients and ensure their BMI is greater than 18.5 and less than 25kg/m2. Any patient with a BMI outside of normal parameters requires a follow-up plan be documented during the current encounter or during the previous twelve months of the current encounter.

Preferred Workflow

1. While documenting the Visit encounter, record the BMI, as appropriate
2. Open the Vitals section and enter the Height and Weight (the BMI is auto-calculated)
3. If the BMI is out of range, the system will display a pop-up encouraging weight counseling education.
4. Open the Preventive Care section
5. Select an option from either the Below or Above Normal BMI Follow-up picklists
6. Add to exam or order the follow-up item(s), as appropriate
7. Continue documenting the encounter, as needed
8. When completed, Close and Archive the encounter

Alternate Workflow

1. While documenting the Visit encounter, record the BMI, as appropriate
2. Open the Vitals section and enter the Height and Weight (the BMI is auto-calculated)
3. If the BMI is out of range, the system will display a pop-up encouraging weight counseling education.
4. Click Yes to add order, as appropriate
5. Continue documenting the encounter, as needed
6. When completed, Close and Archive the encounter

Evidence

Initial Patient Population

Name	Value Set
Encounter, Performed: Encounter to Evaluate BMI	2.16.840.1.113883.3.600.1.1751

Denominator Exclusions

Name	Value Set
Diagnosis: Pregnancy or Other Related Diagnoses	2.16.840.1.113883.3.600.1.1623
Encounter, Performed: Encounter for palliative care	ICD10CM Code Z51.5
Intervention, Order: Hospice Care Ambulatory	2.16.840.1.113883.3.526.3.1584
Intervention, Order: Palliative or Hospice Care	2.16.840.1.113883.3.600.1.1579
Intervention, Performed: Hospice Care Ambulatory	2.16.840.1.113883.3.526.3.1584
Intervention, Performed: Palliative or Hospice Care	2.16.840.1.113883.3.600.1.1579

Numerator

Name	Value Set
Intervention, Order: Follow Up for Above Normal BMI	2.16.840.1.113883.3.600.1.1525
Intervention, Order: Follow Up for Below Normal BMI	2.16.840.1.113883.3.600.1.1528
Intervention, Order: Referrals Where Weight Assessment May Occur	2.16.840.1.113883.3.600.1.1527
Intervention, Performed: Follow Up for Above Normal BMI	2.16.840.1.113883.3.600.1.1525
Intervention, Performed: Follow Up for Below Normal BMI	2.16.840.1.113883.3.600.1.1528
Medication, Order: Medications for Above Normal BMI	2.16.840.1.113883.3.526.3.1561
Medication, Order: Medications for Below Normal BMI	2.16.840.1.113883.3.526.3.1562
Physical Exam, Performed: Body mass index (BMI) [Ratio]	LOINC Code 39156-5

Source(s)

eCQI CMS69