CMS155v12 – Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents

Patients 3-17 years of age by the end of the measurement period, with at least one outpatient visit with a primary care physician (PCP) or an obstetrician/gynecologist (OB/GYN) during the measurement period.

An outpatient visit in this case can include any of the following:

• Office Visit
• Preventive Care Services Individual Counseling
• Preventive Care, Established Office Visit, 0 to 17
• Preventive Care Services, Initial Office Visit, 0 to 17
• Preventive Care Services Group Counseling
• Home Healthcare Services
• Telephone Visits

• Patients who have a diagnosis of pregnancy during the measurement period.
• Patients who are in hospice care for any part of the measurement period.

For Denominator:

To record an encounter, navigate to Patient > Provider Note > Create Superbill. Under the ‘Procedure- CPTs’ heading, enter the relevant encounter code.

For Numerator 1:

Vitals can be recorded through Patient > Provider Note > Vitals. Here, click on ‘Add’ and enter the ‘Weight’ and ‘Height’ of the patient in the respective fields. The system automatically calculates the BMI. Once done, click ‘Accept’.

For Numerator 2 & 3:

To record an intervention, navigate to Patient > Provider Note > Evaluations. Click ‘Add’ and search for a counseling intervention. Select ‘Performed’ from the ‘Status’ drop-down and then click ‘Save & Accept’ or ‘Sign & Accept’. Following codes may be used:

• 183059007
• 183060002
• 183061003
• 103736005
• 183073003
• 281090004

For Denominator Exclusions:

• The pregnancy diagnosis can be documented via Patient > Provider Note > Diagnoses. Click ‘Add’ and search for the relevant diagnosis. Fill out the diagnosis details and once done click ‘Save’. Then click ‘Accept’ to add the diagnosis to the provider note.

• To document that a patient is receiving hospice care outside of a hospital or long-term care facility, navigate to Patient > Provider Note > Evaluations. Use the below mentioned codes to order or perform an intervention:
  • 385763009: Hospice Care (Regime/Therapy)
  • 385765002: Hospice Care Management (Procedure)

• To document an inpatient encounter, navigate to Patient > Provider Note > Evaluations.

• To document a hospice care assessment, follow the workflow Patient > Provider Note > Evaluations. Click ‘Add’ and search for ‘Hospice Care [Minimum Data Set]’. Then select ‘Performed’ from the ‘Status’ dropdown and ‘Yes’ from the ‘Result’ field.

• A hospice encounter can be documented through Patient > Provider Note > Evaluations or Patient > Provider Note > Create Superbill.