CMS69v8 – 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

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

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.

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 record an encounter performed or add the relevant diagnosis along with the associated CPT’s, navigate to Patient > Provider Note > eSuperbill. 

Numerator:

Patients with a documented BMI during the encounter are included in this.

1. Normal BMI

To record BMI, navigate to Patient > Clinical > Vitals. Enter the height and weight of the patient, BMI is then automatically calculated by the system.

2. High BMI Follow Up Encounters:

 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. Use the workflow Patient > Clinical > Evaluations to include a referral.
• Prescribe medication: Add medication for obesity or weight reduction and document it in the provider note. Use the workflow Patient>Provider Note>Prescription to add medication.
• 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.

3. Low BMI Follow Up Encounters

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. Use the workflow Patient > Clinical > Evaluations to include a referral.
• Prescribe medication: Add medication for under-weight in the provider note. Use the workflow Patient>Provider Note>Prescription to add medication.
• 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.

DENOMINATOR EXCEPTIONS

Patients with a documented Medical Reason and medication order is not done are included in the denominator exceptions, In order to do this, navigate to Patient > Clinical > Medication. 

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.

To record patient pregnancy, navigate to the workflow Patient > Provider Note > Diagnosis