CMS69v7 – Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

All patients 18 and older on the date of the encounter with at least one eligible encounter during the measurement period are included.

– DENOMINATOR EXCEPTIONS

Patients with a documented Medical Reason:

1. Elderly Patients (65 or older) for whom weight reduction/weight gain would complicate other underlying health conditions such as the following examples:
   • Illness or physical disability
   • Mental illness, dementia, confusion
   • Nutritional deficiency, such as Vitamin/mineral deficiency
2. 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

– DENOMINATOR EXCLUSIONS

Patients who:

• are pregnant
• are receiving palliative care
• refuse measurement of height and/or weight or refuse follow-up

are included in denominator exclusions.

– NUMERATOR

Once BMI is recorded by entering weight and height there are following conditions:
If BMI is normal then the patient will be automatically added to numerator
If BMI is not normal:

For Overweight:

Documenting any of the following fulfills the requirement of the numerator:

• Perform Intervention: Add follow up
• Perform Intervention: Add referral from Evaluation e.g Refer to weight management program
• Prescribe medication: Add medication for obesity or weight reduction and document it in the provider note.
• Follow up visit: If the follow up visit within the reporting period has BMI down to normal then the patient will be included in the numerator.

For Under Weight:

Documenting any of the following fulfills the requirement of the numerator:

• Perform Intervention: Add follow up
• Perform Intervention: Add referral from Evaluation e.g Refer to weight management program
• Prescribe medication: Add medication for under-weight in the provider note.
• Follow up visit: If the follow up visit within the reporting period has BMI up to normal then the patient will be included in the numerator.

For Denominator:
All patients 18 and older on the date of the encounter with at least one eligible encounter during the measurement period are included. To add the relevant CPT, navigate to Patient > Provider Note > eSuperbill. 

Numerator:

Patients with a documented BMI during the encounter are included in this. To record BMI, navigate to Patient > Clinical > Vitals. Enter the height and weight of the patient, BMI is then automatically calculated by the system.

Documentation for a physical exam i.e. BMI percentile, user can also navigate to Patient > Provider Notes > eSuperbill and enter the relevant CPT codes.

Moreover, a physical exam can also be documented via Patient > Clinical > Evaluations.

For Overweight:

Patients having a higher BMI value than normal qualify for this part of the numerator. To document this, navigate to Patient > Provider Notes > eSuperbill. This intervention can be recorded using the following CPT :

• 43644
• 43842
• 97804
• 99401

For Underweight:

Add referral where you mark the reason as “Under weight”. To document this, navigate to Patient > Clinical > Evaluations.

Follow up visit: If the follow up visit within the reporting period has BMI down to normal then the patient will be included in the numerator.

Prescribe medication:

Add medication for obesity or weight reduction and document it in the provider note.

The prescribed medications list includes:

• Phentermine Hydrochloride
• lorcaserin hydrochloride
• 24 HR Phentermine
• 24 HR lorcaserin hydrochloride
• Orlistat
• Phentermine Hydrochloride
• Diethylpropion Hydrochloride
• Tetrahydrocannabino
• Megestrol Acetate

DENOMINATOR EXCEPTIONS

Patients with a documented Medical Reason and medication order is not done, In order to do this, navigate to Patient > Clinical > Medication.