CMS69v12 – Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

All patients aged 18 and older on the date of the encounter with at least one qualifying encounter during the measurement period.

A qualifying encounter in this case is an encounter to evaluate a patient’s BMI.

– 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.

• A normal BMI range is 5-24.9 kg/m²
• A Low BMI is < 18.5 kg/m²
• A high BMI is > 25 kg/m²

Interventions for BMI outside normal parameters include:

• Follow-ups
• Referrals
• Medication
• Diagnosis (Underweight or Overweight)

– 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. The pregnancy is to be diagnosed during the encounter for evaluating BMI.
• Patients receiving palliative or hospice care at any time during the measurement period.

For Denominator:

To record an encounter, navigate to Patient > Provider Note > Create Superbill. Under the ‘Procedures-CPT’ heading, enter a relevant encounter.

For Numerator:

• To record BMI through vitals, navigate to Patient > Provider Note > Vitals. Click ‘Add’ and enter the weight and height of the patient, through which the system automatically calculates the BMI. Once done, click ‘Accept’.

• To document a follow up intervention for BMI outside normal parameters, head over to Patient > Provider Note > Evaluations. Click ‘Add’ and search for a relevant intervention. From the ‘Status’ drop-down select ‘Performed’. Once done, click ‘Save & Accept’ or ‘Sign & Accept’.

• To document the diagnosis, use the workflow Patient > Provider Note > Diagnoses, and click ‘Add’. Search for the diagnosis, add the diagnosis details, and click ‘Save’. Then click ‘Accept’ to add the diagnosis to the provider note.

• Medication can be ordered via Patient > Provider Note > Prescription. Here, click ‘Add’ and search for the relevant medication, fill out the details and once done, click ‘Prescribe’.

For Denominator Exclusions:

• To record patient pregnancy, navigate to the workflow Patient > Provider Note > Diagnoses.

• To record an encounter, navigate to Patient > Provider Note > Create Superbill.
• For patients receiving palliative care during the measurement period:
  • To record the ‘Palliative Care Encounter’, head over to Patient > Provider Note > Create Superbill

• • To record the ‘Palliative Care Intervention’, use the workflow Patient > Provider Note > Evaluations

• • To record the ‘Functional Assessment of Chronic Illness Therapy’ assessment, navigate to Patient > Provider Note > Evaluations.

• The “Encounter for palliative care” diagnosis can be recorded via Patient > Provider Note > Diagnoses.

• 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.

For Denominator Exceptions:

Note: To document reasons for not recording vitals, users must set preferences from the Personal Module. Navigate to Personal > My Preferences > Patient. Mark the ‘Height/Weight’ checkbox under the ‘Document Reasons for not recording’ heading. Then click ‘Save’.

• To document reasons for not recording BMI, navigate to Patient > Clinical > Vitals. Click on the ‘Save’ button without recording Height and Weight. A pop up ‘Vitals not recorded’ appears. From the Height/Weight dropdown, select the relevant.

• No Follow Up or BMI Referral for abnormal BMI can be recorded through Patient > Provider Note > Evaluations. Here, search for the relevant follow up procedure and set the status to ‘Not Performed’ or ‘Not Ordered’. From the ‘Reason’ dropdown, select the relevant reason.

• The documentation of medical reasons for not prescribing medication can be done via Patient > Provider Note > Medications > Current > Discontinue. Here, the reason for discontinuing an active medication is to be selected from the drop-down.