2022 MIPS Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

Measure Description

Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if most recent BMI was outside of normal parameters.

Instructions

There is no diagnosis associated with this measure. This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. This measure may be submitted by Meritbased Incentive Payment System (MIPS) eligible clinicians 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. 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. 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). If more than one BMI is submitted 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.

Measure Submission Type:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

Denominator

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

Definition:

Not Eligible for BMI Screening or Follow-Up Plan (Denominator Exclusions) – A patient is not eligible if one or more of the following reasons are documented:

• Patients receiving palliative or hospice care on the date of the current encounter or any time prior to the current encounter
• Patients who are pregnant on the date of the current encounter or any time during the measurement period prior to the current encounter

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases):

Patients aged ≥18 years on date of encounter

AND

Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 96156, 96158, 97161, 97162, 97163, 97165, 97166, 97167, 97802, 97803, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99236, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99339, 99340, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, D7111, D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7251, G0101, G0108, G0270, G0271, G0402, G0438, G0439, G0447, G0473

WITHOUT

Telehealth Modifier: GQ, GT, 95, POS 02

AND NOT

DENOMINATOR EXCLUSIONS:

Documentation stating the patient has received or is currently receiving palliative or hospice care: G9996

OR

Documentation of patient pregnancy anytime during the measurement period prior to and including the current encounter: G9997

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

Definitions:

Normal BMI Parameters – Age 18 years and older BMI >= 18.5 and < 25 kg/m2

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 outside 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, physicaltherapist, primary care provider, exercise physiologist, mental health professional, or surgeon), for lifestyle/behavioral therapy
• Pharmacological interventions
• Dietary supplements
• Exercise counseling
• Nutrition counseling

Patients with a Documented Reason for Not Screening BMI (Denominator Exception) - Patient Reason:
• Patients who refuse measurement of height and/or weight on the date of the current encounter or any time during the measurement period prior to the current encounter

OR

Medical Reason:
• Patients with a documented medical reason for not documenting BMI such as 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.

OR

Patients with a Documented Reason for Not Documenting a Follow-up Plan for BMI Outside Normal Parameters (Denominator Exception) - Medical Reason(s):
• Patients (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

Numerator Instructions:

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 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.

Follow-Up Plan – 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. 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).

Performance Met for G8417 & G8418

• • If the provider documents a BMI and a follow-up plan at the current encounter OR
• If the patient has a documented BMI within the previous twelve months of the current encounter, the provider documents a follow-up plan at the current encounter OR
• If the patient has a documented BMI within the previous twelve months of the current encounter AND the patient has a documented follow-up plan for a BMI outside normal parameters within the previous twelve months of the current encounter

Numerator Options:

Performance Met: BMI is documented within normal parameters and no follow-up plan is required (G8420)

OR

Performance Met: BMI is documented as above normal parameters and a follow-up plan is documented (G8417)

OR

Performance Met: BMI is documented as below normal parameters and a follow-up plan is documented (G8418)

OR

Denominator Exception: BMI not documented due to medical reason OR patient refusal of height or weight measurement (G2181)

OR

Denominator Exception: BMI is documented as being outside of normal parameters, follow-up plan is not completed for documented medical reason (G9716)

OR

Performance Not Met: BMI not documented and no reason is given(G8421)

OR

Performance Not Met: BMI documented outside of normal parameters, no follow-up plan documented, no reason given (G8419)

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., 2017). 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. Obesity prevalence was higher among Hispanic men compared with non-Hispanic Black 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 goal 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. p.2-3). Moreover, 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).

Furthermore, 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 inperson, by phone, or electronically (Tronieri et al., 2019). Moreover, Intensive Behavioral Therapy (IBT) 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 and when considering weight management programs for overweight patients, especially the elderly (National Heart, Lung, and Blood Institute [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 percent confidence intervals (CI) = 1.78, 2.90 (Borrell & Samuel, 2014).

Poor nutrition or underlying health conditions can result in underweight (Fryer & 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 to reduce mortality and morbidity associated with underweight.

Clinical Recommendation Statements

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 (Garvey, et al., 2016 AACE/ACE Guidelines, 2016. pp. 12-13) (Grade A).

Overweight and Underweight Categories:
Underweight 40 (Garvey, et al., 2016 AACE/ACE Guidelines, 2016. p. 15)..

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 AACE/ACE Guidelines, 2016,. p. 13) (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 AACE/ACE Guidelines, 2016. p. 22) (Grade A).

Behavioral lifestyle intervention should be tailored to a patient’s ethnic, cultural, socioeconomic, and educational background (Garvey, et al., 2016 AACE/ACE Guidelines, 2016. p. 22) (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.

Interventions:

• Effective intensive behavioral interventions were designed to help participants achieve or maintain a 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) (Grade B) (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, 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).