CMS 69v11: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

Measure: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the measurement period AND who had a follow-up plan documented if most recent BMI was outside of normal parameters

Measure Type High Priority Measure Scoring
Process No A higher percentage indicates better quality
Denominator All patients 18 and older on the date of the encounter with at least one eligible encounter during the measurement period
Numerator Patients with a documented BMI during the encounter or during the measurement period, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the measurement period
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
Denominator Exclusions
  • Patients who are pregnant at any time during the measurement period
  • Patients receiving palliative or hospice care at any time during the measurement period

Patients who meet the following criteria will be included in the denominator:

  • Age is ≥ 18 years at the beginning of the Measurement Period

    AND

  • Have at least one eligible encounter during the Measurement Period finalized by the EC

CPT: 90791, 90792, 90832, 90834, 90837, 96156, 96158, 96159, 97161, 97162, 97163, 97165, 97166, 97167, 97802, 97803, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99236, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99339, 99340, 99385, 99386, 99387, 99395, 99396, 99397, 99401, 99402

HCPCS: G0101, G0108, G0270, G0271, G0402, G0438, G0439, G0447, G0473

Note: Telephone encounters are not eligible for the denominator.

A patient will be counted as an exception if there is a medical reason or urgent medical situation for not documenting their BMI or for not providing a BMI follow up plan if BMI was out of the normal range. A patient who refuses to have their height or weight measured will also be counted as an exception.

The reason for the exception must be documented on the day of the eligible encounter.

  1. Go to Encounter > Flowsheets/Labs > Standard
  2. From the BMI – Adult flowsheet, click Add Column
  3. Select Emergent situation, Has a terminal illness, Medical reason, or Physical disability from the No BMI obtained due to list
  4. Click OK to save

  1. Go to Encounter > Flowsheets/Labs > Standard
  2. From the BMI – Adult flowsheet, click Add Column
  3. Select a Value from the BMI Management Plan not done due to list
  4. Click OK to save

  1. Go to Encounter > Flowsheets/Labs > Standard
  2. From the BMI – Adult flowsheet, click Add Column
  3. Select Patient Refused from the No BMI obtained due to list
  4. Click OK to save

A patient will be excluded from this measure if they meet any of the following conditions:

  • Has an active diagnosis of pregnancy at any time during the Measurement Period
  • Is in hospice care at any time during the Measurement Period
  • Is receiving palliative care at any time during the Measurement Period

Diagnoses are documented in the Assessment tab of an encounter. A comprehensive list of eligible pregnancy diagnosis codes can be located here.

To document hospice care ambulatory services, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

CPT: 99377, 99378

HCPCS: G0182

Order Status must be marked as Pending or Complete.

To document hospice care encounter services, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

HCPCS: G9996, G9473, G9474, G9475, G9476, G9477, G9478, G9479, Q5003, Q5004, Q5005, Q5006, Q5007, Q5008, Q5010, S9126, T2042, T2043, T2044, T2045, T2046

Order Status must be marked as Complete.

Palliative care services can be documented using the FACIT-Pal Questionnaire flowsheet, as an order, or as a diagnosis.

  1. Go to Encounter > Flowsheets/Labs > Standard or Chart > Flowsheets/Labs > Standard

  2. Click Add New Flowsheet

  3. Select the FACIT-Pal Questionnaire flowsheet and click Add

  4. Click Add Column

  5. Populate the patient's responses to the questions as appropriate

  6. Click OK to save

Go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

HCPCS: G9054, M1017

Order Status must be marked as Complete.

Diagnoses are documented in the Assessment tab of an encounter. The eligible diagnosis code for palliative care is:

ICD-10: Z51.5

A patient will be counted in the numerator if their BMI was documented during the eligible encounter or during the Measurement Period. If the patient’s BMI is outside of the normal range (as defined by this measure), a BMI follow up plan must be provided to the patient during the eligible encounter or during the Measurement Period.

This measure defines Normal BMI Parameters as: Age 18 years and older BMI ≥ 18.5 and < 25 kg/m2

If more than one BMI is documented during the Measurement Period, and any of the documented BMI assessments is outside of normal parameters, documentation of an appropriate follow-up plan will be used to determine if performance has been met.

BMI is calculated based on the patient height and weight as entered in the Vitals tab of an encounter.

To document height and weight, go to Encounter > Vitals and click Add/Retake Vitals

The BMI follow up plan can be documented in any of the following ways:

  • As a referral in the BMI – Adult flowsheet

  • As an active or resolved diagnosis

  • As a procedure

  • As a prescription for medication

The BMI follow up plan must be provided on the day of the eligible encounter or during the Measurement Period.

  1. Go to Encounter > Flowsheets/Labs > Standard
  2. From the BMI – Adult flowsheet, click Add Column
  3. Select a Value from the BMI Referral to list
  4. Click OK to save

This action does not create a referral in Sevocity. Referrals are created from the Referrals tab in the chart or from the Orders/Referrals tab in an encounter

Diagnoses are documented in the Assessment tab of an encounter. The eligible diagnosis codes for BMI follow up plan are:

Above Normal BMI Follow Up

ICD-10: Z71.3, Z71.82

Below Normal BMI Follow Up

ICD-10: Z71.3

To document a BMI follow up plan as a procedure, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

Above Normal BMI Follow Up

CPT: 43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43888, 97802, 97803, 97804, 98960, 99078, 99401, 99402

HCPCS: G0270, G0271, G0447, G0473, S9449, S9451, S9452, S9470

Below Normal BMI Follow Up

CPT: 97802, 97803, 97804, 98960, 99078, 99401, 99402

HCPCS: G0270, G0271, S9449, S9452, S9470

Order Status must be marked as Pending or Complete.

To prescribe a medication, go to Encounter > Medications > Manage/Prescribe Meds > New Prescription. A comprehensive list of eligible BMI management medications can be located here.

https://ecqi.healthit.gov/ecqm/ec/2023/cms069v11

 

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