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Measure: CMS69

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

Measure Versions

eMeasure Code Measure Year Full Version Number Title
CMS69v10 2022 10.1.000 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
CMS69v9 2021 9.3.000 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
CMS69v8 2020 8.2.000 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
CMS69v7 2019 7.1.000 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
CMS69v6 2018 6.1.000 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
CMS69v5 2017 5.0.000 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

Description

Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2

Guidance

* There is no diagnosis associated with this measure. * This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. * This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided at the time of the qualifying visit and the measure-specific denominator coding. BMI Measurement Guidance: * Height and Weight - An eligible professional or their staff is required to measure both height and weight. Both height and weight must be measured within twelve months of the current encounter and may be obtained from separate encounters. Self-reported values cannot be used. * The BMI may be documented in the medical record of the provider or in outside medical records obtained by the provider. * If the most recent documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter. * If more than one BMI is reported during the measurement period, the most recent BMI will be used to determine if the performance has been met. * Review the exclusions and exceptions criteria to determine those patients that BMI measurement may not be appropriate or necessary. Follow-Up Plan Guidance: * The documented follow-up plan must be based on the most recent documented BMI, outside of normal parameters, example: "Patient referred to nutrition counseling for BMI above or below normal parameters." (See Definitions for examples of follow-up plan treatments). Variation has been noted in studies exploring optimal BMI ranges for the elderly (see Donini et al., (2012); Holme and Tonstad (2015); and Diehr et al. (2008). Notably however, all these studies have arrived at ranges that differ from the standard range for ages 18 and older, which is >=18.5 and < 25 kg/m2. For instance, both Donini et al. (2012) and Holme and Tonstad (2015) reported findings that suggest that higher BMI (higher than the upper end of 25kg/m2) in the elderly may be beneficial. Similarly, worse outcomes have been associated with being underweight (at a threshold higher than 18.5 kg/m2) at age 65 (Diehr et al. 2008). Because of optimal BMI range variation recommendations from these studies, no specific optimal BMI range for the elderly is used. However, It may be appropriate to exempt certain patients from a follow-up plan by applying the exception criteria. Review the following to apply the Medical Reason exception criteria: The Medical Reason exception could include, but is not limited to, the following patients as deemed appropriate by the health care provider: * 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 * 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

Patient Group Definitions

Group Description Instructions Links
Initial PopulationAll patients 18 and older on the date of the encounter with at least one eligible encounter during the measurement periodWebchart Instructions
DenominatorEquals Initial PopulationWebchart Instructions
Denominator ExclusionsPatients who are pregnant Patients receiving palliative care Patients who refuse measurement of height and/or weight or refuse follow-upWebchart Instructions
NumeratorPatients 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 encounterWebchart Instructions
Numerator ExclusionsNot ApplicableWebchart Instructions
Denominator ExceptionsPatients 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 statusWebchart Instructions

Details

Full eMeasure Code eMeasure Identifier Measure Year Version NQF # GUID
CMS69v7 69 2019 7.1.000 0421 9A031BB8-3D9B-11E1-8634-00237D5BF174
Steward Developer Endorsed By
Quality Insights Centers for Medicare & Medicaid Services (CMS) National Quality Forum
Scoring Method Measure Type Stratification Risk Adjustment
Proportion PROCESS None None

Rate Aggregation

None

Improvement Notation

Higher score indicates better quality

Rationale

BMI Above Normal Parameters Obesity is a chronic, multifactorial disease with complex psychological, environmental (social and cultural), genetic, physiologic, metabolic and behavioral causes and consequences. The prevalence of overweight and obese people is increasing worldwide at an alarming rate in both developing and developed countries. Environmental and behavioral changes brought about by economic development, modernization and urbanization have been linked to the rise in global obesity. The health consequences are becoming apparent (ICSI 2013. p.6). Hales et al (2017), report that the prevalence of obesity among adults and youth in the United States was 39.8% and 18.5% respectively, from 2015-2016. They note that obesity prevalence was higher among adults in the 40-59 age bracket than those in the 20-39 age bracket, for both men and women. Hales et al. (2017) also disaggregated the data according to ethnicity and noted that obesity prevalence was higher among non-Hispanic black and Hispanic adults and youth when compared with other races ethnicities. While obesity prevalence was lower among non-Hispanic Asian men and women, obesity prevalence among men, was comparable between non-Hispanic black and non-Hispanic white men. Obesity prevalence was higher among Hispanic men compared with non-Hispanic black men. While the prevalence among non-Hispanic black and Hispanic women was comparable, the prevalence for both groups was higher than that of non-Hispanic white women. Most notably, Hales et al (2017), report that the prevalence of obesity in the United States remains higher than the Healthy People 2020 goals of 14.5% among youth and 30.5% among adults. More than a third of U.S. adults have a body mass index [BMI] >= 30 kg/m2; substantially at increased risk for diabetes and cardiovascular disease (CVD) (Flegal et al., 2012; Ogden et al., 2014). Behavioral weight management treatment has been identified as an effective first-line treatment for obesity with an average initial weight loss of 8-10%. This percentage weight loss is associated with a significant risk reduction for diabetes and CVD (Butryn et al., 2011; Wadden et al., 2012). Despite the availability of effective interventions, two-thirds of obese U.S. patients were not offered or referred to weight management treatment during their primary care visit between 2005 and 2006, (Ma et al., 2009). In addition, the rate of weight management counseling in primary care significantly decreased by 10% (40% to 30%) between 1995-1996 and 2007-2008 (Kraschnewski et al., 2013). This suggests that the availability of evidence based clinical guidelines since 2008 obesity management in primary care remains suboptimal (Fitzpatrick S.L., Stevens, V. J., 2017, pp 128-132). BMI continues to be a common and reasonably reliable measurement to identify overweight and obese adults who may be at an increased risk for future morbidity. Although good quality evidence supports obtaining a BMI, it is important to recognize it is not a perfect measurement. BMI is not a direct measure of adiposity and as a consequence it can over- or underestimate adiposity. BMI is a derived value that correlates well with total body fat and markers of secondary complications, eg, hypertension and dyslipidemia (Barlow, 2007). In contrast with waist circumference, BMI and its associated disease and mortality risk appear to vary among ethnic subgroups. Female African American populations appear to have the lowest mortality risk at a BMI of 26.2-28.5 kg/m2 and 27.1-30.2 kg/m2 for women and men, respectively. In contrast, Asian populations may experience lowest mortality rates starting at a BMI of 23 to 24 kg/m2. The correlation between BMI and diabetes risk also varies by ethnicity (LeBlanc, 2011. p.2-3) Screening for BMI and follow-up therefore is critical to closing this gap and contributes to quality goals of population health and cost reduction. However, due to concerns for other underlying conditions (such as bone health) or nutrition related deficiencies providers are cautioned to use clinical judgment and take these into account when considering weight management programs for overweight patients, especially the elderly (NHLBI Obesity Education Initiative, 1998, p. 91). BMI below Normal Parameters On the other end of the body weight spectrum is underweight (BMI <18.5 kg/m2), which is equally detrimental to population health. When compared to normal weight individuals(BMI 18.5-25 kg/m2), underweight individuals have significantly higher death rates with a Hazard Ratio of 2.27 and 95% confidence intervals (CI) = 1.78, 2.90 (Borrell & Lalitha (2014). Poor nutrition or underlying health conditions can result in underweight (Fryer & Ogden, 2012). The National Health and Nutrition Examination Survey (NHANES) results from the 2007-2010 indicate that women are more likely to be underweight than men (2012). Therefore patients should be equally screened for underweight and followed up with nutritional counselling to reduce mortality and morbidity associated with underweight.

Clinical Recommendation Statement

All adults should be screened annually using a BMI measurement. BMI measurements >=25kg/m2 should be used to initiate further evaluation of overweight or obesity after taking into account age, gender, ethnicity, fluid status, and muscularity; therefore, clinical evaluation and judgment must be used when BMI is employed as the anthropometric indicator of excess adiposity, particularly in athletes and those with sarcopenia (AACE/ACE Guidelines, 2016. pp. 12-13) (Grade A).

Overweight and Underweight Categories:
Underweight   <18.5; Normal weight 18.5-24.9; Overweight 25-29.9; Obese class I 30-34.9; Obese class II 35-39.9; Obese class III >=40 (AACE/ACE Guidelines, 2016. p. 15).

When evaluating patients for adiposity related disease risk, waist circumference should be measured in all patients with BMI <35 kg/m2 (AACE/ACE Guidelines, 2016. p. 13) (Grade A).

In the United States the waist circumference cutoff points that can be used to indicate increased risk are >=102 cm (>40 inches) for men and >=88 cm (more than >35 inches) for women (AACE/ACE Guidelines, 2016. p. 13) (Grade A).

Lifestyle/Behavioral Therapy for Overweight and Obesity should include behavioral interventions that enhance adherence to prescriptions for a reduced-calorie meal plan and increased physical activity (behavioral interventions can include: self-monitoring of weight, food intake, and physical activity; clear and reasonable goal-setting; education pertaining to obesity, nutrition, and physical activity; face-to-face and group meetings; stimulus control; systematic approaches for problem solving; stress reduction; cognitive restructuring [i.e., cognitive behavioral therapy], motivational interviewing; behavioral contracting; psychological counseling; and mobilization of social support structures) (AACE/ACE Guidelines, 2016. p. 22) (Grade A).

Behavioral lifestyle intervention should be tailored to a patient's ethnic, cultural, socioeconomic, and educational background (AACE/ACE Guidelines, 2016. p. 22) (Grade B).
	
USPSTF Clinical Guideline (Grade B Recommendation)  
Individuals with a body mass index (BMI) of 30 kg/m2 or higher should be offered or referred to intensive, multicomponent behavioral interventions that include the following components:
- Behavioral management activities, such as setting weight-loss goals
- Improving diet or nutrition and increasing physical activity
- Addressing barriers to change
- Self-monitoring
- Strategizing how to maintain lifestyle changes

Nutritional safety for the elderly should be considered when recommending weight reduction. "A clinical decision to forego obesity treatment in older adults should be guided by an evaluation of the potential benefits of weight reduction for day-to-day functioning and reduction of the risk of future cardiovascular events, as well as the patient's motivation for weight reduction. Care must be taken to ensure that any weight reduction program minimizes the likelihood of adverse effects on bone health or other aspects of nutritional status" (NHLBI Obesity Education Initiative, 1998, p. 91) (Evidence Category D). In addition, weight reduction prescriptions in older persons should be accompanied by proper nutritional counseling and regular body weight monitoring. (NHLBI Obesity Education Initiative, 1998, p. 91).

The possibility that a standard approach to weight loss will work differently in diverse patient populations must be considered when setting expectations about treatment outcomes (NHLBI Obesity Education Initiative, 1998, p. 97) (Evidence Category B).

Definition

BMI- Body mass index (BMI) is a number calculated using the Quetelet index: weight divided by height squared (W/H2) and is commonly used to classify weight categories. BMI can be calculated using: Metric Units: BMI = Weight (kg) / (Height (m) x Height (m)) OR English Units: BMI = Weight (lbs.) / (Height (in) x Height (in)) x 703 Follow-Up Plan - Proposed outline of treatment to be conducted as a result of a BMI out of normal parameters. A follow-up plan may include, but is not limited to: documentation of education, referral (for example a Registered Dietitian Nutritionist (RDN), occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional, or surgeon) for lifestyle/behavioral therapy, pharmacological interventions, dietary supplements, exercise counseling or nutrition counseling.

Transmission Format

TBD

Applicable Value Sets

Category Value Set OID
Diagnosis Pregnancy Dx 2.16.840.1.113883.3.600.1.1623
Encounter, Performed BMI Encounter Code Set 2.16.840.1.113883.3.600.1.1751
Encounter, Performed Palliative Care Encounter 2.16.840.1.113883.3.600.1.1575
Intervention, Not Ordered Above Normal Follow-up 2.16.840.1.113883.3.600.1.1525
Intervention, Not Ordered Below Normal Follow up 2.16.840.1.113883.3.600.1.1528
Intervention, Not Ordered Referrals where weight assessment may occur 2.16.840.1.113883.3.600.1.1527
Intervention, Order Above Normal Follow-up 2.16.840.1.113883.3.600.1.1525
Intervention, Order Below Normal Follow up 2.16.840.1.113883.3.600.1.1528
Intervention, Order Palliative Care 2.16.840.1.113883.3.600.1.1579
Intervention, Order Referrals where weight assessment may occur 2.16.840.1.113883.3.600.1.1527
Medication, Not Ordered Above Normal Medications 2.16.840.1.113883.3.600.1.1498
Medication, Not Ordered Below Normal Medications 2.16.840.1.113883.3.600.1.1499
Medication, Order Above Normal Medications 2.16.840.1.113883.3.600.1.1498
Medication, Order Below Normal Medications 2.16.840.1.113883.3.600.1.1499
Patient Characteristic Ethnicity Ethnicity 2.16.840.1.114222.4.11.837
Patient Characteristic Payer Payer 2.16.840.1.114222.4.11.3591
Patient Characteristic Race Race 2.16.840.1.114222.4.11.836
Patient Characteristic Sex ONC Administrative Sex 2.16.840.1.113762.1.4.1

References

Barlow SE, The Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120:S164-92.
Barnes P. M., & Schoenborn, C.A. (2012). Trends in adults receiving a recommendation for exercise or other physical activity from a physician or other health professional. Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) Data Brief, No. 86: Feb 2012.
Borrell, L. N., & Samuel, L. (2014). Body mass index categories and mortality risk in US adults: The effect of overweight and obesity on advancing death.  American Journal of Public Health, 104, 512-519.
Diehr P., O'Meara, E.S., Fitzpatrick A., Newman, A. B., Kuller, L., Burke, G. (2008). Weight, mortality, years of healthy life, and active life expectancy in older adults. Journal of American Geriatrics Society, 56, 76-83.
Donini, L. M., Savina, C., Gennaro, E., De Felice, M. R., Rosano, A., Pandolfo, M. M., ... Chumlea, W. C. (2012). A Systematic Review Of The Literature Concerning The Relationship Between Obesity And Mortality In The Elderly. The Journal of Nutrition, Health & Aging, 16(1), 89-98.
Finkelstein, E. A., Trogdon, J. G., Cohen, J. W., & Dietz, W. (2009). Annual Medical Spending Attributable To Obesity: Payer-and Service-Specific Estimates. Health Affairs, 28(5), w822-w831.  doi:  10.1377/hlthaff.28.5.w822
Fitch A., Everling L., Fox C., Goldberg, J., Heim, C., Johnson, K., Kaufman, T., Kennedy, E., Kestenbaun, C., Lano, M., Leslie, D., Newell, T., O'Connor, P., Slusarek, B., Spaniol, A., Stovitz, S., Webb, B.. Institute for Clinical Systems Improvement. Prevention and Management of Obesity for Adults, 4-10. Updated May 2013.
Fitzpatrick, S. L., & Stevens, V. J. (June 01, 2017). Adult obesity management in primary care, 2008-2013. Preventive Medicine, 99, 128-133. Retrieved from http://dx.doi.org/10.1016/j.ypmed.2017.02.020
Fryar, C. D., & Ogden, C. L. (2012). Prevalence of underweight among adults aged 20 and over: United States, 1960-1962 through 2007-2010. National Center for Health Statistics, Division of Health and Nutrition Examination Surveys. Retrieved from http://www.cdc.gov/nchs/data/hestat/underweight_adult_07_10/underweight_adult_07_10.pdf
Garvey, W. T., Mechanick, J. I., Brett, E. M., Garber, A. J., Hurley, D. L., Jastreboff, A. M., Nadolsky, K., ... Reviewers of the AACE/ACE Obesity Clinical Practice Guidelines. (January 01, 2016). American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. Endocrine Practice: Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists, 12, 13, 15, 22.
Hales, C.M., Carroll, M. D., Fryar, C. D., Ogden, C. L., (2017). Prevalence of obesity among adults and youth: United States, 2015-2016. NCHS data brief, no 288, 6. October 2017. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db288.htm
Holme, I., & Tonstad, S. (2015) Survival in elderly men in relation to midlife and current BMI. Age and Ageing, 44, 3, 434-9.
LeBlanc, E., O'Connor. E., Whitlock, E. P., et al. (2011). Screening for and management of obesity and overweight in adults. Evidence Report No. 89. AHRQ Publication No. 11-05159-EF-1. Rockville, MD: Agency for Healthcare Research and Quality. October 2011.
NHLBI Obesity Education Initiative. (1998). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults.
Wilkinson, J., Bass, C., Diem, S., Gravley, A., Harvey, L. Hayes, R., Johnson, K., Maciosek, M., McKeon, K., Milteer, L., Morgan, J., Rothe, P., Snellman, L., Solberg, L., Storlie, C., & Vincent, P. (2013). Institute for Clinical Systems Improvement. Preventive Services for Adults.

Disclaimer

These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

Copyright

Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. Quality Insights, Inc. disclaims all liability for use or accuracy of any Current Procedural Terminology (CPT[R]) or other coding contained in the specifications.

CPT(R) contained in the Measure specifications is copyright 2007-2017 American Medical Association. LOINC(R) copyright 2004-2017 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2017 International Health Terminology Standards Development Organisation. All Rights Reserved.

Source: https://ecqi.healthit.gov/ecqm/measures/cms69v7