Title: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanFHIR Id: PCSBMIScreenAndFollowUpFHIR Download cql: PCSBMIScreenAndFollowUpFHIR.cql Version: 0.1.000 Url: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanFHIR short-name identifier: CMS69FHIR version-independent identifier: urn:uuid:5d929142-0109-4dc3-97b5-27c9296b3cf9 version-specific identifier: urn:uuid:1039b9aa-b444-4112-ad53-1a86e16f9fcc publisher (CMS) identifier: 69FHIR Effective Period: 2024-01-01 ..2024-12-31 Status: draft Date: 2023-08-28 11:59:32+0000 Approval Date: 2023-08-28 Last Review Date: 2023-08-28 Name: PCSBMIScreenAndFollowUpFHIR Publisher: Centers for Medicare & Medicaid Services (CMS) Author: Mathematica: https://www.mathematica.org/ Description: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the measurement period AND who had a follow-up plan documented if BMI was outside of normal parameters Use Context: code value program Purpose: UNKNOWN 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. CPT(R) contained in the Measure specifications is copyright 2004-2022 American Medical Association. LOINC(R) is copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2022 World Health Organization. All Rights Reserved. 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]. 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” (Fitch et al., 2013). More than a third of U.S. adults have a body mass index [BMI] >= 30 kg/m2 and are at increased risk for diabetes, cardiovascular disease (CVD), and obstructive sleep apnea (Flegal et al., 2012; Ogden et al., 2015; Dong et al., 2020). Hales et al. (2017), reported that the prevalence of obesity among adults and youth in the United States was 39.8 percent and 18.5 percent respectively, from 2015-2016. Furthermore, the prevalence of obesity in adults increased to 42.4 percent in 2018, with the highest percentage among adults in the 40-59 age bracket compared with other age groups (Hales et al., 2020). Hales et al. (2020) also disaggregated the data according to race/ethnicity and noted that obesity prevalence was higher among non-Hispanic Black adults and Hispanic adults when compared with other races and ethnicities. Obesity prevalence was lowest among non-Hispanic Asian men and women. Among men, obesity prevalence was higher among Hispanic men compared with non-Hispanic Black men and non-Hispanic White men. Among women, the prevalence among non-Hispanic Black women was 56.9 percent, which was higher than all other race/ethnicities. In general, the prevalence of obesity in the U.S. remains higher than the Healthy People 2020 goals of 30.5 percent among adults (Hales et al., 2020). 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. For example, BMI and its associated disease and mortality risk appear to vary among ethnic subgroups. Black/African Americans appear to have the lowest mortality risk at a BMI of 26.2-28.5 kg/m2 in Black women and 27.1-30.2 kg/m2 in Black men. 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 et al., 2011). BMI is not a direct measure of adiposity and as a consequence, it can over or underestimate adiposity. However, overall, BMI is a derived value that correlates well with total body fat and markers of secondary complications, e.g., hypertension and dyslipidemia (Barlow & the Expert Committee, 2007). It is important to enhance beneficiary access to appropriate treatments for obesity, which could result in decreased healthcare costs and lower obesity rates. Behavioral weight management treatment has been identified as an effective first-line treatment for obesity with an average initial weight loss of 8-10 percent. This percentage weight loss is associated with a significant risk reduction for diabetes and CVD (Wadden, Butryn & Wilson, 2007). Evidence also shows that when provided 14 or more high-intensity behavioral intervention sessions of face-to-face individual or group treatment across 6 months, participants lose up to 8 percent of their weight during that time and experience improvements in heart disease risk factors and quality of life (Wadden, Tronieri, & Butryn, 2020). There is also evidence that high-intensity behavioral counseling is effective, whether delivered in-person, by phone, or electronically (Tronieri et al., 2019). Moreover, intensive behavioral therapy for obesity provided by registered dietitian nutritionists for 6-12 months shows significant mean weight loss of up to 10 percent of body weight, maintained over one year’s time (Raynor & Champagne, 2016). Despite the evidence that supports weight management counseling, the rate of use in primary care for patients with obesity decreased by 10 percent from 39.9 percent in 1995-1996 to 29.9 percent in 2007-2008 (Kraschnewski et al., 2013). Weight management counseling during primary care visits further declined from 33 percent to 21 percent between 2008-2009 and 2012-2013. This suggests that obesity management in primary care remains suboptimal (Fitzpatrick & Stevens, 2017). Therefore, screening for BMI and follow-up is critical and will help in reaching the 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 their best clinical judgment when considering weight management programs for overweight patients, especially the elderly (National Heart, Lung, and Blood Institute [NHLBI] Obesity Education Initiative, 1998). BMI Below Normal Parameters On the other end of the body weight spectrum is underweight (BMI < 18.5 kg/m2), which is also 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 percent confidence intervals = 1.78, 2.90 (Borrell & Samuel, 2014). Individuals with a BMI < 18.5 kg/m2 have been shown to be at a higher risk for adverse events, postoperative infection, and/or mortality following a surgical procedure (Katakam, et al., 2021; Ottesen et al., 2020; Ottesen et al., 2022; Rudasill et al., 2021). BMI below normal parameters is a risk factor for developing severe illness from respiratory infections such as influenza and COVID-19 (Moser et al., 2019; Ye et al., 2021). BMI below normal parameters can negatively impact both male and female fertility (Boutari et al., 2020; Guo et al., 2019). Poor nutrition or underlying health conditions can result in underweight (Fryar & Ogden, 2012). The National Health and Nutrition Examination Survey (NHANES) results from 2007-2010 indicate that women are more likely to be underweight than men (Centers for Disease Control and Prevention, 2012). However, all patients should be equally screened for underweight and followed up with nutritional counseling or another clinically appropriate intervention to reduce mortality and morbidity associated with underweight. Clinical recommendation statement: All adults should be screened annually using a BMI measurement. BMI measurements >= 25 kg/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 (Garvey et al., 2016) (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 (Garvey et al., 2016). BMI cutoff point value of >= 23 kg/m2 should be used in the screening and confirmation of excess adiposity in Asian adults (Garvey et al., 2016) (Grade B). 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) (Garvey et al., 2016) (Grade A). Behavioral lifestyle intervention should be tailored to a patient's ethnic, cultural, socioeconomic, and educational background (Garvey et al., 2016) (Grade B). The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians offer or refer adults with a BMI of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions (USPSTF, 2018) (Grade B). Interventions: Effective intensive behavioral interventions were designed to help participants achieve or maintain weight loss of at least five percent through a combination of dietary changes and increased physical activity Most interventions lasted for one to two years, and the majority had at least 12 sessions in the first year Most behavioral interventions focused on problem solving to identify barriers, self-monitoring of weight, peer support, and relapse prevention Interventions also provided tools to support weight loss or weight loss maintenance (e.g., pedometers, food scales, or exercise videos) (USPSTF, 2018) 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) (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). 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) (Evidence Category B). Guidance (Usage): 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 during the measurement period. 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 documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the measurement period. - If more than one BMI is reported during the measurement period, and any of the documented BMI assessments is outside of normal parameters, documentation of an appropriate follow-up plan will be used to determine if 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 documented BMI, outside of normal parameters, example: "Patient referred to nutrition counseling for BMI above or below normal parameters." See the Definition section 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 & Tonstad, 2015; 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. and Holme and Tonstad reported findings that suggest that higher BMI (higher than the upper end of 25 kg/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. See Denominator Exception section for examples. This eCQM is a patient-based measure. This measure is to be reported a minimum of once per measurement period for patients seen during the measurement 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 encounter and the measure-specific denominator coding. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This FHIR-based measure has been derived from the QDM-based measure: CMS69v12. Please refer to the HL7 QI-Core Implementation Guide (http://hl7.org/fhir/us/qicore/index.html) for more information on QI-Core and mapping recommendations from QDM to QI-Core 4.1.1 (http://hl7.org/fhir/us/qicore/qdm-to-qicore.html). Population Criteria: 643465ae7c12bd4a0fdf28c8 Initial Population: All patients aged 18 and older on the date of the encounter with at least one qualifying encounter during the measurement period Denominator: Equals Initial Population Denominator Exclusion: Patients who are pregnant at any time during the measurement period. Patients receiving palliative or hospice care at any time during the measurement period. 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 Numerator Exclusion: None Denominator Exception: 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. Supplemental Data Guidance : Supplemental Data Elements: SDE Ethnicity SDE Payer SDE Race SDE Sex Libraries: PCSBMIScreenAndFollowUpFHIR Related Artifact Dependencies: Library/SupplementalDataElements|3.4.000 Library/FHIRHelpers|4.3.000 Library/QICoreCommon|1.5.000 Library/FHIRHelpers|4.3.000 Library/FHIRHelpers|4.3.000 Library/Hospice|6.7.000 Library/Status|1.6.000 Library/QICoreCommon|1.5.000 Library/FHIRHelpers|4.3.000 Library/PalliativeCare|1.7.000 Condition Category Codes US Core Condition Category Extension Codes Condition Clinical Status Codes ActCode SNOMED CT (all versions) Observation Category Codes LOINC LOINC Follow Up for Above Normal BMI Referrals Where Weight Assessment May Occur Medications for Above Normal BMI Overweight or Obese Follow Up for Below Normal BMI Medications for Below Normal BMI Underweight Encounter to Evaluate BMI Payer Encounter Inpatient Hospice Encounter Hospice Care Ambulatory Hospice Diagnosis Palliative Care Diagnosis Palliative Care Encounter Palliative Care Intervention Pregnancy or Other Related Diagnoses Medical Reason Patient Declined Parameters: name use min max type Measurement Period In 0 1 Period SDE Sex Out 0 1 Coding Numerator Out 0 1 boolean Denominator Out 0 1 boolean SDE Payer Out 0 * Resource Initial Population Out 0 1 boolean SDE Ethnicity Out 0 1 Resource Denominator Exclusions Out 0 1 boolean SDE Race Out 0 1 Resource Denominator Exceptions Out 0 1 boolean DataRequirements: Type Elements Valueset Name Valueset Patient(QICorePatient) Patient(http://hl7.org/fhir/Patient) gender gender.value birthDate birthDate.value Observation(Observation Body Mass Index Profile) value status status.value effective Observation(Observation Body Mass Index Profile) value status status.value effective Condition(http://hl7.org/fhir/Condition) clinicalStatus ServiceRequest(QICoreServiceRequest) code Follow Up for Above Normal BMI Follow Up for Above Normal BMI ServiceRequest(QICoreServiceRequest) code Referrals Where Weight Assessment May Occur Referrals Where Weight Assessment May Occur MedicationRequest(QICoreMedicationRequest) medication Medications for Above Normal BMI Medications for Above Normal BMI MedicationRequest(QICoreMedicationRequest) medication Medications for Above Normal BMI Medications for Above Normal BMI Condition(QICoreCondition) code Overweight or Obese Overweight or Obese Procedure(QICoreProcedure) code reasonCode status status.value performed Follow Up for Above Normal BMI Follow Up for Above Normal BMI Condition(QICoreCondition) code Overweight or Obese Overweight or Obese Patient(QICorePatient) Observation(Observation Body Mass Index Profile) value status status.value effective Observation(Observation Body Mass Index Profile) value status status.value effective ServiceRequest(QICoreServiceRequest) code Follow Up for Below Normal BMI Follow Up for Below Normal BMI ServiceRequest(QICoreServiceRequest) code Referrals Where Weight Assessment May Occur Referrals Where Weight Assessment May Occur MedicationRequest(QICoreMedicationRequest) medication Medications for Below Normal BMI Medications for Below Normal BMI MedicationRequest(QICoreMedicationRequest) medication Medications for Below Normal BMI Medications for Below Normal BMI Condition(QICoreCondition) code Underweight Underweight Procedure(QICoreProcedure) code reasonCode status status.value performed Follow Up for Below Normal BMI Follow Up for Below Normal BMI Condition(QICoreCondition) code Underweight Underweight Observation(Observation Body Mass Index Profile) value status status.value effective Observation(Observation Body Mass Index Profile) value status status.value effective Encounter(QICoreEncounter) type period class status status.value Encounter to Evaluate BMI Encounter to Evaluate BMI Patient(QICorePatient) Encounter(QICoreEncounter) type period class status status.value Encounter to Evaluate BMI Encounter to Evaluate BMI Coverage(QICoreCoverage) type period Payer Type Payer uri(http://hl7.org/fhir/uri) value Patient(QICorePatient) url extension Patient(QICorePatient) url extension Encounter(QICoreEncounter) type Encounter Inpatient Encounter Inpatient Encounter(QICoreEncounter) type hospitalization hospitalization.dischargeDisposition period Encounter Inpatient Encounter Inpatient Encounter(QICoreEncounter) type Hospice Encounter Hospice Encounter Encounter(QICoreEncounter) type period Hospice Encounter Hospice Encounter Observation(QICoreObservation) code Observation(QICoreObservation) code value effective ServiceRequest(QICoreServiceRequest) code Hospice Care Ambulatory Hospice Care Ambulatory ServiceRequest(QICoreServiceRequest) code authoredOn authoredOn.value Hospice Care Ambulatory Hospice Care Ambulatory Procedure(QICoreProcedure) code Hospice Care Ambulatory Hospice Care Ambulatory Procedure(QICoreProcedure) code performed Hospice Care Ambulatory Hospice Care Ambulatory Condition(QICoreCondition) code Hospice Diagnosis Hospice Diagnosis Observation(QICoreObservation) code Observation(QICoreObservation) code effective Condition(QICoreCondition) code Palliative Care Diagnosis Palliative Care Diagnosis Encounter(QICoreEncounter) type Palliative Care Encounter Palliative Care Encounter Encounter(QICoreEncounter) type period Palliative Care Encounter Palliative Care Encounter Procedure(QICoreProcedure) code Palliative Care Intervention Palliative Care Intervention Procedure(QICoreProcedure) code performed Palliative Care Intervention Palliative Care Intervention Condition(QICoreCondition) code clinicalStatus Pregnancy or Other Related Diagnoses Pregnancy or Other Related Diagnoses Encounter(QICoreEncounter) type period class status status.value Encounter to Evaluate BMI Encounter to Evaluate BMI Patient(QICorePatient) url extension Patient(QICorePatient) url extension ServiceRequest(QICoreServiceNotRequested) code Referrals Where Weight Assessment May Occur Referrals Where Weight Assessment May Occur ServiceRequest(QICoreServiceNotRequested) code Referrals Where Weight Assessment May Occur Referrals Where Weight Assessment May Occur ServiceRequest(QICoreServiceNotRequested) code Follow Up for Above Normal BMI Follow Up for Above Normal BMI ServiceRequest(QICoreServiceNotRequested) code Follow Up for Above Normal BMI Follow Up for Above Normal BMI ServiceRequest(QICoreServiceNotRequested) code Follow Up for Below Normal BMI Follow Up for Below Normal BMI ServiceRequest(QICoreServiceNotRequested) code Follow Up for Below Normal BMI Follow Up for Below Normal BMI Encounter(QICoreEncounter) type period class status status.value Encounter to Evaluate BMI Encounter to Evaluate BMI MedicationRequest(QICoreMedicationNotRequested) medication Medications for Above Normal BMI Medications for Above Normal BMI MedicationRequest(QICoreMedicationNotRequested) medication Medications for Above Normal BMI Medications for Above Normal BMI MedicationRequest(QICoreMedicationNotRequested) medication Medications for Below Normal BMI Medications for Below Normal BMI MedicationRequest(QICoreMedicationNotRequested) medication Medications for Below Normal BMI Medications for Below Normal BMI Encounter(QICoreEncounter) type period class status status.value Encounter to Evaluate BMI Encounter to Evaluate BMI Observation(QICoreObservationNotDone) code effective status status.value extension Encounter(QICoreEncounter) type period class status status.value Encounter to Evaluate BMI Encounter to Evaluate BMI Encounter(QICoreEncounter) type period class status status.value Encounter to Evaluate BMI Encounter to Evaluate BMI Coverage(QICoreCoverage) type period Payer Type Payer Patient(QICorePatient) url extension Patient(QICorePatient) url extension Direct Reference Codes: display code system Problem List Item problem-list-item http://terminology.hl7.org/CodeSystem/condition-category Health Concern health-concern http://hl7.org/fhir/us/core/CodeSystem/condition-category active http://terminology.hl7.org/CodeSystem/condition-clinical recurrence http://terminology.hl7.org/CodeSystem/condition-clinical relapse http://terminology.hl7.org/CodeSystem/condition-clinical virtual VR http://terminology.hl7.org/CodeSystem/v3-ActCode Discharge to home for hospice care (procedure) 428361000124107 http://snomed.info/sct Discharge to healthcare facility for hospice care (procedure) 428371000124100 http://snomed.info/sct survey survey http://terminology.hl7.org/CodeSystem/observation-category Hospice care [Minimum Data Set] 45755-6 http://loinc.org Yes (qualifier value) 373066001 http://snomed.info/sct Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal) 71007-9 http://loinc.org Body mass index (BMI) [Ratio] 39156-5 http://loinc.org Logic Definitions: Group Scoring Population Criteria Expression 643465ae7c12bd4a0fdf28c8 Group scoring: proportion Initial Population define "Initial Population": exists "Qualifying Encounter during Day of Measurement Period" QualifyingEncounter where "AgeInYearsAt"(date from start of QualifyingEncounter.period) >= 18 Denominator define "Denominator": "Initial Population" Denominator Exclusion define "Denominator Exclusions": Hospice."Has Hospice Services" or PalliativeCare."Has Palliative Care in the Measurement Period" or exists "Pregnancy" Numerator define "Numerator": exists "High BMI and Follow up Provided" or exists "Low BMI and Follow up Provided" or "Has Normal BMI" Numerator Exclusion None Denominator Exception define "Denominator Exceptions": exists "Medical Reason for Not Documenting a Follow up Plan for Low or High BMI" or exists "Medical Reason or Patient Reason for Not Performing BMI Exam" Library Name Name SupplementalDataElements SDE Sex define "SDE Sex": case when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' } when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' } else null end Library Name Name PCSBMIScreenAndFollowUpFHIR SDE Sex define "SDE Sex": SDE."SDE Sex" Library Name Name PCSBMIScreenAndFollowUpFHIR BMI during Measurement Period define "BMI during Measurement Period": ["observation-bmi"] BMI where BMI.value > 0 'kg/m2' and BMI.status in { 'final', 'amended', 'corrected' } and BMI.effective.toInterval ( ) during day of "Measurement Period" Library Name Name PCSBMIScreenAndFollowUpFHIR Documented High BMI during Measurement Period define "Documented High BMI during Measurement Period": "BMI during Measurement Period" BMI where BMI.effective.toInterval ( ) during day of "Measurement Period" and BMI.value >= 25 'kg/m2' Library Name Name PCSBMIScreenAndFollowUpFHIR High BMI Interventions Ordered define "High BMI Interventions Ordered": ( ( [ServiceRequest: "Follow Up for Above Normal BMI"] union [ServiceRequest: "Referrals Where Weight Assessment May Occur"] union [MedicationRequest: "Medications for Above Normal BMI"] ) HighInterventionsOrdered where HighInterventionsOrdered.reasonCode in "Overweight or Obese" or ( exists [Condition: "Overweight or Obese"] OverweightObese where ( OverweightObese.isProblemListItem ( ) or OverweightObese.isHealthConcern ( ) ) and OverweightObese.isActive ( ) and OverweightObese.prevalenceInterval ( ) starts before or on day of HighInterventionsOrdered.authoredOn and not ( OverweightObese.prevalenceInterval ( ) ends before day of HighInterventionsOrdered.authoredOn ) ) ) Library Name Name PCSBMIScreenAndFollowUpFHIR High BMI Interventions Performed define "High BMI Interventions Performed": ( [Procedure: "Follow Up for Above Normal BMI"] HighInterventionsPerformed where HighInterventionsPerformed.reasonCode in "Overweight or Obese" and HighInterventionsPerformed.status = 'completed' or ( exists [Condition: "Overweight or Obese"] OverweightObese where OverweightObese.isHealthConcern ( ) and OverweightObese.isActive ( ) and OverweightObese.prevalenceInterval ( ) starts before or on day of HighInterventionsPerformed.performed.toInterval ( ) and not ( OverweightObese.prevalenceInterval ( ) ends before day of HighInterventionsPerformed.performed.toInterval ( ) ) ) ) Library Name Name PCSBMIScreenAndFollowUpFHIR High BMI and Follow up Provided define "High BMI and Follow up Provided": "Documented High BMI during Measurement Period" HighBMI with ( "High BMI Interventions Ordered" union "High BMI Interventions Performed" ) HighBMIInterventions such that Coalesce(HighBMIInterventions.performed.toInterval(), HighBMIInterventions.authoredOn.toInterval()) starts during day of "Measurement Period" Library Name Name PCSBMIScreenAndFollowUpFHIR Documented Low BMI during Measurement Period define "Documented Low BMI during Measurement Period": "BMI during Measurement Period" BMI where BMI.effective.toInterval ( ) during day of "Measurement Period" and BMI.value < 18.5 'kg/m2' Library Name Name PCSBMIScreenAndFollowUpFHIR Low BMI Interventions Ordered define "Low BMI Interventions Ordered": ( ( [ServiceRequest: "Follow Up for Below Normal BMI"] union [ServiceRequest: "Referrals Where Weight Assessment May Occur"] union [MedicationRequest: "Medications for Below Normal BMI"] ) LowInterventionsOrdered where LowInterventionsOrdered.reasonCode in "Underweight" or ( exists [Condition: "Underweight"] Underweight where ( Underweight.isHealthConcern ( ) ) and Underweight.isActive ( ) and Underweight.prevalenceInterval ( ) starts before or on day of LowInterventionsOrdered.authoredOn and not ( Underweight.prevalenceInterval ( ) ends before day of LowInterventionsOrdered.authoredOn ) and LowInterventionsOrdered.authoredOn during day of "Measurement Period" ) ) Library Name Name PCSBMIScreenAndFollowUpFHIR Low BMI Interventions Performed define "Low BMI Interventions Performed": ( [Procedure: "Follow Up for Below Normal BMI"] LowInterventionsPerformed where LowInterventionsPerformed.reasonCode in "Underweight" and LowInterventionsPerformed.status = 'completed' or ( exists [Condition: "Underweight"] Underweight where ( Underweight.isHealthConcern ( ) ) and Underweight.isActive ( ) and Underweight.prevalenceInterval ( ) starts before or on day of LowInterventionsPerformed.performed.toInterval ( ) and not ( Underweight.prevalenceInterval ( ) ends before day of LowInterventionsPerformed.performed.toInterval ( ) and LowInterventionsPerformed.performed.toInterval ( ) during day of "Measurement Period" ) ) ) Library Name Name PCSBMIScreenAndFollowUpFHIR Low BMI and Follow up Provided define "Low BMI and Follow up Provided": ( "Documented Low BMI during Measurement Period" LowBMI with ( "Low BMI Interventions Ordered" union "Low BMI Interventions Performed" ) LowBMIInterventions such that Coalesce(LowBMIInterventions.performed.toInterval(), LowBMIInterventions.authoredOn.toInterval()) starts during day of "Measurement Period" ) Library Name Name PCSBMIScreenAndFollowUpFHIR Has Normal BMI define "Has Normal BMI": exists ( "BMI during Measurement Period" BMI where BMI.value in Interval[18.5 'kg/m2', 24.9 'kg/m2'] ) and not ( exists "Documented High BMI during Measurement Period" or exists "Documented Low BMI during Measurement Period" ) Library Name Name PCSBMIScreenAndFollowUpFHIR Numerator define "Numerator": exists "High BMI and Follow up Provided" or exists "Low BMI and Follow up Provided" or "Has Normal BMI" Library Name Name PCSBMIScreenAndFollowUpFHIR Qualifying Encounter during Day of Measurement Period define "Qualifying Encounter during Day of Measurement Period": [Encounter: "Encounter to Evaluate BMI"] BMIEncounter where BMIEncounter.period during day of "Measurement Period" and BMIEncounter.class !~ "virtual" and BMIEncounter.status = 'finished' Library Name Name PCSBMIScreenAndFollowUpFHIR Initial Population define "Initial Population": exists "Qualifying Encounter during Day of Measurement Period" QualifyingEncounter where "AgeInYearsAt"(date from start of QualifyingEncounter.period) >= 18 Library Name Name PCSBMIScreenAndFollowUpFHIR Denominator define "Denominator": "Initial Population" Library Name Name SupplementalDataElements SDE Payer define "SDE Payer": [Coverage: type in "Payer Type"] Payer return { code: Payer.type, period: Payer.period } Library Name Name PCSBMIScreenAndFollowUpFHIR SDE Payer define "SDE Payer": SDE."SDE Payer" Library Name Name SupplementalDataElements SDE Ethnicity define "SDE Ethnicity": Patient.ethnicity E return Tuple { codes: { E.ombCategory } union E.detailed, display: E.text } Library Name Name PCSBMIScreenAndFollowUpFHIR SDE Ethnicity define "SDE Ethnicity": SDE."SDE Ethnicity" Library Name Name Hospice Has Hospice Services define "Has Hospice Services": exists ((([Encounter: "Encounter Inpatient"]).isEncounterPerformed()) InpatientEncounter where (InpatientEncounter.hospitalization.dischargeDisposition ~ "Discharge to home for hospice care (procedure)" or InpatientEncounter.hospitalization.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)" ) and InpatientEncounter.period.toInterval() ends during day of "Measurement Period" ) or exists ((([Encounter: "Hospice Encounter"]).isEncounterPerformed()) HospiceEncounter where HospiceEncounter.period.toInterval() overlaps day of "Measurement Period" ) or exists ((([Observation: "Hospice care [Minimum Data Set]"]).isAssessmentPerformed()) HospiceAssessment where HospiceAssessment.value ~ "Yes (qualifier value)" and HospiceAssessment.effective.toInterval() overlaps day of "Measurement Period" ) or exists ((([ServiceRequest: "Hospice Care Ambulatory"]).isInterventionOrder()) HospiceOrder where HospiceOrder.authoredOn.toInterval() during day of "Measurement Period" ) or exists ((([Procedure: "Hospice Care Ambulatory"]).isInterventionPerformed()) HospicePerformed where HospicePerformed.performed.toInterval() overlaps day of "Measurement Period" ) or exists (([Condition: "Hospice Diagnosis"]) HospiceCareDiagnosis where HospiceCareDiagnosis.prevalenceInterval() overlaps day of "Measurement Period" ) Library Name Name PalliativeCare Has Palliative Care in the Measurement Period define "Has Palliative Care in the Measurement Period": exists ((([Observation: "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)"]).isAssessmentPerformed()) PalliativeAssessment where PalliativeAssessment.effective.toInterval() overlaps day of "Measurement Period" ) or exists ([Condition: "Palliative Care Diagnosis"] PalliativeDiagnosis where PalliativeDiagnosis.prevalenceInterval() overlaps day of "Measurement Period" ) or exists ((([Encounter: "Palliative Care Encounter"]).isEncounterPerformed()) PalliativeEncounter where PalliativeEncounter.period.toInterval() overlaps day of "Measurement Period" ) or exists ((([Procedure: "Palliative Care Intervention"]).isInterventionPerformed()) PalliativeIntervention where PalliativeIntervention.performed.toInterval() overlaps day of "Measurement Period" ) Library Name Name PCSBMIScreenAndFollowUpFHIR Pregnancy define "Pregnancy": [Condition: "Pregnancy or Other Related Diagnoses"] PregnancyDiagnosis with "Qualifying Encounter during Day of Measurement Period" QualifyingEncounter such that PregnancyDiagnosis.clinicalStatus ~ QICoreCommon."active" and PregnancyDiagnosis.prevalenceInterval ( ) overlaps day of "Measurement Period" Library Name Name PCSBMIScreenAndFollowUpFHIR Denominator Exclusions define "Denominator Exclusions": Hospice."Has Hospice Services" or PalliativeCare."Has Palliative Care in the Measurement Period" or exists "Pregnancy" Library Name Name SupplementalDataElements SDE Race define "SDE Race": Patient.race R return Tuple { codes: R.ombCategory union R.detailed, display: R.text } Library Name Name PCSBMIScreenAndFollowUpFHIR SDE Race define "SDE Race": SDE."SDE Race" Library Name Name PCSBMIScreenAndFollowUpFHIR Medical Reason for Not Documenting a Follow up Plan for Low or High BMI define "Medical Reason for Not Documenting a Follow up Plan for Low or High BMI": ( ( [ServiceNotRequested: "Referrals Where Weight Assessment May Occur"] union [ServiceNotRequested: "Follow Up for Above Normal BMI"] union [ServiceNotRequested: "Follow Up for Below Normal BMI"] ) NoBMIFollowUp with "Qualifying Encounter during Day of Measurement Period" QualifyingEncounter such that NoBMIFollowUp.authoredOn same day as start of QualifyingEncounter.period where NoBMIFollowUp.status ~ 'completed' and NoBMIFollowUp.reasonRefused in "Medical Reason" ) union ( ( [MedicationNotRequested: "Medications for Above Normal BMI"] union [MedicationNotRequested: "Medications for Below Normal BMI"] ) NoBMIFollowUp with "Qualifying Encounter during Day of Measurement Period" QualifyingEncounter such that NoBMIFollowUp.authoredOn same day as start of QualifyingEncounter.period where NoBMIFollowUp.status ~ 'completed' and NoBMIFollowUp.reasonCode in "Medical Reason" ) Library Name Name PCSBMIScreenAndFollowUpFHIR Medical Reason or Patient Reason for Not Performing BMI Exam define "Medical Reason or Patient Reason for Not Performing BMI Exam": [ObservationNotDone: code = "Body mass index (BMI) [Ratio]"] NoBMI with "Qualifying Encounter during Day of Measurement Period" QualifyingEncounter such that NoBMI.effective.toInterval ( ) ends same day as start of QualifyingEncounter.period where NoBMI.status = 'cancelled' and ( NoBMI.notDoneReason in "Patient Declined" or NoBMI.notDoneReason in "Medical Reason" ) Library Name Name PCSBMIScreenAndFollowUpFHIR Denominator Exceptions define "Denominator Exceptions": exists "Medical Reason for Not Documenting a Follow up Plan for Low or High BMI" or exists "Medical Reason or Patient Reason for Not Performing BMI Exam"
Discharge to home for hospice care (procedure)
Discharge to healthcare facility for hospice care (procedure)
Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)
define "SDE Sex": case when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' } when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' } else null end
define "BMI during Measurement Period": ["observation-bmi"] BMI where BMI.value > 0 'kg/m2' and BMI.status in { 'final', 'amended', 'corrected' } and BMI.effective.toInterval ( ) during day of "Measurement Period"
Documented High BMI during Measurement Period
define "Documented High BMI during Measurement Period": "BMI during Measurement Period" BMI where BMI.effective.toInterval ( ) during day of "Measurement Period" and BMI.value >= 25 'kg/m2'
define "High BMI Interventions Ordered": ( ( [ServiceRequest: "Follow Up for Above Normal BMI"] union [ServiceRequest: "Referrals Where Weight Assessment May Occur"] union [MedicationRequest: "Medications for Above Normal BMI"] ) HighInterventionsOrdered where HighInterventionsOrdered.reasonCode in "Overweight or Obese" or ( exists [Condition: "Overweight or Obese"] OverweightObese where ( OverweightObese.isProblemListItem ( ) or OverweightObese.isHealthConcern ( ) ) and OverweightObese.isActive ( ) and OverweightObese.prevalenceInterval ( ) starts before or on day of HighInterventionsOrdered.authoredOn and not ( OverweightObese.prevalenceInterval ( ) ends before day of HighInterventionsOrdered.authoredOn ) ) )
define "High BMI Interventions Performed": ( [Procedure: "Follow Up for Above Normal BMI"] HighInterventionsPerformed where HighInterventionsPerformed.reasonCode in "Overweight or Obese" and HighInterventionsPerformed.status = 'completed' or ( exists [Condition: "Overweight or Obese"] OverweightObese where OverweightObese.isHealthConcern ( ) and OverweightObese.isActive ( ) and OverweightObese.prevalenceInterval ( ) starts before or on day of HighInterventionsPerformed.performed.toInterval ( ) and not ( OverweightObese.prevalenceInterval ( ) ends before day of HighInterventionsPerformed.performed.toInterval ( ) ) ) )
define "High BMI and Follow up Provided": "Documented High BMI during Measurement Period" HighBMI with ( "High BMI Interventions Ordered" union "High BMI Interventions Performed" ) HighBMIInterventions such that Coalesce(HighBMIInterventions.performed.toInterval(), HighBMIInterventions.authoredOn.toInterval()) starts during day of "Measurement Period"
Documented Low BMI during Measurement Period
define "Documented Low BMI during Measurement Period": "BMI during Measurement Period" BMI where BMI.effective.toInterval ( ) during day of "Measurement Period" and BMI.value < 18.5 'kg/m2'
define "Low BMI Interventions Ordered": ( ( [ServiceRequest: "Follow Up for Below Normal BMI"] union [ServiceRequest: "Referrals Where Weight Assessment May Occur"] union [MedicationRequest: "Medications for Below Normal BMI"] ) LowInterventionsOrdered where LowInterventionsOrdered.reasonCode in "Underweight" or ( exists [Condition: "Underweight"] Underweight where ( Underweight.isHealthConcern ( ) ) and Underweight.isActive ( ) and Underweight.prevalenceInterval ( ) starts before or on day of LowInterventionsOrdered.authoredOn and not ( Underweight.prevalenceInterval ( ) ends before day of LowInterventionsOrdered.authoredOn ) and LowInterventionsOrdered.authoredOn during day of "Measurement Period" ) )
define "Low BMI Interventions Performed": ( [Procedure: "Follow Up for Below Normal BMI"] LowInterventionsPerformed where LowInterventionsPerformed.reasonCode in "Underweight" and LowInterventionsPerformed.status = 'completed' or ( exists [Condition: "Underweight"] Underweight where ( Underweight.isHealthConcern ( ) ) and Underweight.isActive ( ) and Underweight.prevalenceInterval ( ) starts before or on day of LowInterventionsPerformed.performed.toInterval ( ) and not ( Underweight.prevalenceInterval ( ) ends before day of LowInterventionsPerformed.performed.toInterval ( ) and LowInterventionsPerformed.performed.toInterval ( ) during day of "Measurement Period" ) ) )
define "Low BMI and Follow up Provided": ( "Documented Low BMI during Measurement Period" LowBMI with ( "Low BMI Interventions Ordered" union "Low BMI Interventions Performed" ) LowBMIInterventions such that Coalesce(LowBMIInterventions.performed.toInterval(), LowBMIInterventions.authoredOn.toInterval()) starts during day of "Measurement Period" )
define "Has Normal BMI": exists ( "BMI during Measurement Period" BMI where BMI.value in Interval[18.5 'kg/m2', 24.9 'kg/m2'] ) and not ( exists "Documented High BMI during Measurement Period" or exists "Documented Low BMI during Measurement Period" )
define "Numerator": exists "High BMI and Follow up Provided" or exists "Low BMI and Follow up Provided" or "Has Normal BMI"
Qualifying Encounter during Day of Measurement Period
define "Qualifying Encounter during Day of Measurement Period": [Encounter: "Encounter to Evaluate BMI"] BMIEncounter where BMIEncounter.period during day of "Measurement Period" and BMIEncounter.class !~ "virtual" and BMIEncounter.status = 'finished'
define "Initial Population": exists "Qualifying Encounter during Day of Measurement Period" QualifyingEncounter where "AgeInYearsAt"(date from start of QualifyingEncounter.period) >= 18
define "Denominator": "Initial Population"
define "SDE Payer": [Coverage: type in "Payer Type"] Payer return { code: Payer.type, period: Payer.period }
define "SDE Ethnicity": Patient.ethnicity E return Tuple { codes: { E.ombCategory } union E.detailed, display: E.text }
define "SDE Ethnicity": SDE."SDE Ethnicity"
define "Has Hospice Services": exists ((([Encounter: "Encounter Inpatient"]).isEncounterPerformed()) InpatientEncounter where (InpatientEncounter.hospitalization.dischargeDisposition ~ "Discharge to home for hospice care (procedure)" or InpatientEncounter.hospitalization.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)" ) and InpatientEncounter.period.toInterval() ends during day of "Measurement Period" ) or exists ((([Encounter: "Hospice Encounter"]).isEncounterPerformed()) HospiceEncounter where HospiceEncounter.period.toInterval() overlaps day of "Measurement Period" ) or exists ((([Observation: "Hospice care [Minimum Data Set]"]).isAssessmentPerformed()) HospiceAssessment where HospiceAssessment.value ~ "Yes (qualifier value)" and HospiceAssessment.effective.toInterval() overlaps day of "Measurement Period" ) or exists ((([ServiceRequest: "Hospice Care Ambulatory"]).isInterventionOrder()) HospiceOrder where HospiceOrder.authoredOn.toInterval() during day of "Measurement Period" ) or exists ((([Procedure: "Hospice Care Ambulatory"]).isInterventionPerformed()) HospicePerformed where HospicePerformed.performed.toInterval() overlaps day of "Measurement Period" ) or exists (([Condition: "Hospice Diagnosis"]) HospiceCareDiagnosis where HospiceCareDiagnosis.prevalenceInterval() overlaps day of "Measurement Period" )
Has Palliative Care in the Measurement Period
define "Has Palliative Care in the Measurement Period": exists ((([Observation: "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)"]).isAssessmentPerformed()) PalliativeAssessment where PalliativeAssessment.effective.toInterval() overlaps day of "Measurement Period" ) or exists ([Condition: "Palliative Care Diagnosis"] PalliativeDiagnosis where PalliativeDiagnosis.prevalenceInterval() overlaps day of "Measurement Period" ) or exists ((([Encounter: "Palliative Care Encounter"]).isEncounterPerformed()) PalliativeEncounter where PalliativeEncounter.period.toInterval() overlaps day of "Measurement Period" ) or exists ((([Procedure: "Palliative Care Intervention"]).isInterventionPerformed()) PalliativeIntervention where PalliativeIntervention.performed.toInterval() overlaps day of "Measurement Period" )
define "Pregnancy": [Condition: "Pregnancy or Other Related Diagnoses"] PregnancyDiagnosis with "Qualifying Encounter during Day of Measurement Period" QualifyingEncounter such that PregnancyDiagnosis.clinicalStatus ~ QICoreCommon."active" and PregnancyDiagnosis.prevalenceInterval ( ) overlaps day of "Measurement Period"
define "Denominator Exclusions": Hospice."Has Hospice Services" or PalliativeCare."Has Palliative Care in the Measurement Period" or exists "Pregnancy"
define "SDE Race": Patient.race R return Tuple { codes: R.ombCategory union R.detailed, display: R.text }
Medical Reason for Not Documenting a Follow up Plan for Low or High BMI
define "Medical Reason for Not Documenting a Follow up Plan for Low or High BMI": ( ( [ServiceNotRequested: "Referrals Where Weight Assessment May Occur"] union [ServiceNotRequested: "Follow Up for Above Normal BMI"] union [ServiceNotRequested: "Follow Up for Below Normal BMI"] ) NoBMIFollowUp with "Qualifying Encounter during Day of Measurement Period" QualifyingEncounter such that NoBMIFollowUp.authoredOn same day as start of QualifyingEncounter.period where NoBMIFollowUp.status ~ 'completed' and NoBMIFollowUp.reasonRefused in "Medical Reason" ) union ( ( [MedicationNotRequested: "Medications for Above Normal BMI"] union [MedicationNotRequested: "Medications for Below Normal BMI"] ) NoBMIFollowUp with "Qualifying Encounter during Day of Measurement Period" QualifyingEncounter such that NoBMIFollowUp.authoredOn same day as start of QualifyingEncounter.period where NoBMIFollowUp.status ~ 'completed' and NoBMIFollowUp.reasonCode in "Medical Reason" )
Medical Reason or Patient Reason for Not Performing BMI Exam
define "Medical Reason or Patient Reason for Not Performing BMI Exam": [ObservationNotDone: code = "Body mass index (BMI) [Ratio]"] NoBMI with "Qualifying Encounter during Day of Measurement Period" QualifyingEncounter such that NoBMI.effective.toInterval ( ) ends same day as start of QualifyingEncounter.period where NoBMI.status = 'cancelled' and ( NoBMI.notDoneReason in "Patient Declined" or NoBMI.notDoneReason in "Medical Reason" )
define "Denominator Exceptions": exists "Medical Reason for Not Documenting a Follow up Plan for Low or High BMI" or exists "Medical Reason or Patient Reason for Not Performing BMI Exam"
Code system USCoreConditionCategoryExtensionCodes
Code system ConditionClinicalStatusCodes
Value set Follow Up for Above Normal BMI
Value set Referrals Where Weight Assessment May Occur
Value set Medications for Above Normal BMI
Value set Follow Up for Below Normal BMI
Value set Medications for Below Normal BMI
Value set Pregnancy or Other Related Diagnoses
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanFHIR
Centers for Medicare & Medicaid Services (CMS)
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the measurement period AND who had a follow-up plan documented if BMI was outside of normal parameters
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 during the measurement period. 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 documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the measurement period. - If more than one BMI is reported during the measurement period, and any of the documented BMI assessments is outside of normal parameters, documentation of an appropriate follow-up plan will be used to determine if 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 documented BMI, outside of normal parameters, example: "Patient referred to nutrition counseling for BMI above or below normal parameters." See the Definition section 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 & Tonstad, 2015; 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. and Holme and Tonstad reported findings that suggest that higher BMI (higher than the upper end of 25 kg/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. See Denominator Exception section for examples. This eCQM is a patient-based measure. This measure is to be reported a minimum of once per measurement period for patients seen during the measurement 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 encounter and the measure-specific denominator coding. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This FHIR-based measure has been derived from the QDM-based measure: CMS69v12. Please refer to the HL7 QI-Core Implementation Guide (http://hl7.org/fhir/us/qicore/index.html) for more information on QI-Core and mapping recommendations from QDM to QI-Core 4.1.1 (http://hl7.org/fhir/us/qicore/qdm-to-qicore.html).
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. CPT(R) contained in the Measure specifications is copyright 2004-2022 American Medical Association. LOINC(R) is copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2022 World Health Organization. All Rights Reserved.
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].
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” (Fitch et al., 2013). More than a third of U.S. adults have a body mass index [BMI] >= 30 kg/m2 and are at increased risk for diabetes, cardiovascular disease (CVD), and obstructive sleep apnea (Flegal et al., 2012; Ogden et al., 2015; Dong et al., 2020). Hales et al. (2017), reported that the prevalence of obesity among adults and youth in the United States was 39.8 percent and 18.5 percent respectively, from 2015-2016. Furthermore, the prevalence of obesity in adults increased to 42.4 percent in 2018, with the highest percentage among adults in the 40-59 age bracket compared with other age groups (Hales et al., 2020). Hales et al. (2020) also disaggregated the data according to race/ethnicity and noted that obesity prevalence was higher among non-Hispanic Black adults and Hispanic adults when compared with other races and ethnicities. Obesity prevalence was lowest among non-Hispanic Asian men and women. Among men, obesity prevalence was higher among Hispanic men compared with non-Hispanic Black men and non-Hispanic White men. Among women, the prevalence among non-Hispanic Black women was 56.9 percent, which was higher than all other race/ethnicities. In general, the prevalence of obesity in the U.S. remains higher than the Healthy People 2020 goals of 30.5 percent among adults (Hales et al., 2020). 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. For example, BMI and its associated disease and mortality risk appear to vary among ethnic subgroups. Black/African Americans appear to have the lowest mortality risk at a BMI of 26.2-28.5 kg/m2 in Black women and 27.1-30.2 kg/m2 in Black men. 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 et al., 2011). BMI is not a direct measure of adiposity and as a consequence, it can over or underestimate adiposity. However, overall, BMI is a derived value that correlates well with total body fat and markers of secondary complications, e.g., hypertension and dyslipidemia (Barlow & the Expert Committee, 2007). It is important to enhance beneficiary access to appropriate treatments for obesity, which could result in decreased healthcare costs and lower obesity rates. Behavioral weight management treatment has been identified as an effective first-line treatment for obesity with an average initial weight loss of 8-10 percent. This percentage weight loss is associated with a significant risk reduction for diabetes and CVD (Wadden, Butryn & Wilson, 2007). Evidence also shows that when provided 14 or more high-intensity behavioral intervention sessions of face-to-face individual or group treatment across 6 months, participants lose up to 8 percent of their weight during that time and experience improvements in heart disease risk factors and quality of life (Wadden, Tronieri, & Butryn, 2020). There is also evidence that high-intensity behavioral counseling is effective, whether delivered in-person, by phone, or electronically (Tronieri et al., 2019). Moreover, intensive behavioral therapy for obesity provided by registered dietitian nutritionists for 6-12 months shows significant mean weight loss of up to 10 percent of body weight, maintained over one year’s time (Raynor & Champagne, 2016). Despite the evidence that supports weight management counseling, the rate of use in primary care for patients with obesity decreased by 10 percent from 39.9 percent in 1995-1996 to 29.9 percent in 2007-2008 (Kraschnewski et al., 2013). Weight management counseling during primary care visits further declined from 33 percent to 21 percent between 2008-2009 and 2012-2013. This suggests that obesity management in primary care remains suboptimal (Fitzpatrick & Stevens, 2017). Therefore, screening for BMI and follow-up is critical and will help in reaching the 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 their best clinical judgment when considering weight management programs for overweight patients, especially the elderly (National Heart, Lung, and Blood Institute [NHLBI] Obesity Education Initiative, 1998). BMI Below Normal Parameters On the other end of the body weight spectrum is underweight (BMI < 18.5 kg/m2), which is also 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 percent confidence intervals = 1.78, 2.90 (Borrell & Samuel, 2014). Individuals with a BMI < 18.5 kg/m2 have been shown to be at a higher risk for adverse events, postoperative infection, and/or mortality following a surgical procedure (Katakam, et al., 2021; Ottesen et al., 2020; Ottesen et al., 2022; Rudasill et al., 2021). BMI below normal parameters is a risk factor for developing severe illness from respiratory infections such as influenza and COVID-19 (Moser et al., 2019; Ye et al., 2021). BMI below normal parameters can negatively impact both male and female fertility (Boutari et al., 2020; Guo et al., 2019). Poor nutrition or underlying health conditions can result in underweight (Fryar & Ogden, 2012). The National Health and Nutrition Examination Survey (NHANES) results from 2007-2010 indicate that women are more likely to be underweight than men (Centers for Disease Control and Prevention, 2012). However, all patients should be equally screened for underweight and followed up with nutritional counseling or another clinically appropriate intervention to reduce mortality and morbidity associated with underweight.
All adults should be screened annually using a BMI measurement. BMI measurements >= 25 kg/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 (Garvey et al., 2016) (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 (Garvey et al., 2016). BMI cutoff point value of >= 23 kg/m2 should be used in the screening and confirmation of excess adiposity in Asian adults (Garvey et al., 2016) (Grade B). 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) (Garvey et al., 2016) (Grade A). Behavioral lifestyle intervention should be tailored to a patient's ethnic, cultural, socioeconomic, and educational background (Garvey et al., 2016) (Grade B). The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians offer or refer adults with a BMI of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions (USPSTF, 2018) (Grade B). Interventions: - Effective intensive behavioral interventions were designed to help participants achieve or maintain weight loss of at least five percent through a combination of dietary changes and increased physical activity - Most interventions lasted for one to two years, and the majority had at least 12 sessions in the first year - Most behavioral interventions focused on problem solving to identify barriers, self-monitoring of weight, peer support, and relapse prevention - Interventions also provided tools to support weight loss or weight loss maintenance (e.g., pedometers, food scales, or exercise videos) (USPSTF, 2018) 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) (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). 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) (Evidence Category B).
All patients aged 18 and older on the date of the encounter with at least one qualifying encounter during the measurement period
Patients who are pregnant at any time during the measurement period. Patients receiving palliative or hospice care at any time during the measurement period.
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
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.