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

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Updated: 12/09/2021
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CMS 69 / Quality ID #128

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 the most recent BMI was outside of normal parameters.

Normal Parameters:	Age 18 years and older BMI => 18.5 and <25 kg/m²
Denominator:	All patients aged 18 years and older on the date of the encounter with at least one eligible encounter during the measurement period. Patient’s age is calculated based on the patient’s Date of Birth, which was entered when you created the patient’s account. Create a note detailing the patient’s office visit.
Denominator Exclusions:	If patient is pregnant: "Pregnancy" is documented in the Problem List, with a Start Date. These patients will be excluded from the denominator. If patient was in Hospice during the measurement period: Hospice is documented under Hospitalizations/Procedures in History. These patients will be excluded from the denominator.
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). Or, patients who refuse measurement of height and/or weight. On the date of service, click on Care Checklist from within the note. Select "Excepted" for Abnormal BMI Follow-up on the date that it was discussed with the patient which should be the date of the note. Select Medical Contraindication from the drop-down. If patient refused BMI measurement: Select "Patient refused to provide weight and/or height" from Vitals, then click Save. These patients will be excluded from the denominator.
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. BMI is calculated based on Height and Weight entered in Vitals. Select "Completed" for Abnormal BMI Follow-up in the Care Checklist on the date that it was discussed with the patient which should be the date of the note.
Office Visit Documentation:	Enter Procedure Codes including E/M Codes or HCPCS Codes on the Superbill. Complete and sign the note. Note: Select "Not Completed" for Abnormal BMI Follow-up in the Care Checklist when the follow-up plan was not completed by the provider. Once all steps have been completed, the measure will be added to the Quality Measures Report.
Guidance:	The most recent BMI will be used to determine if the performance has been met.
Measure type:	Process
Telehealth Eligible:	No