2025 MIPS Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

Quality ID 128

eMeasure ID CMS69v13

High Priority Measure No

Specifications EHR Registry

Measure Type Process

Registry Link Registry

EHR Link EHR

Specialty N/A

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 the 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.

NOTE: This measure specification is only available for MIPS Value Pathways (MVP) reporting and is not available for traditional MIPS reporting.

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 qualifying 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, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99424, 99491, D7111, D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7251, G0101, G0108, G0270, G0271, G0402, G0438, G0439, G0447, G0473

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, FQ, 93, POS 02, POS 10

WITHOUT

Place of Service (POS): 12

AND NOT

DENOMINATOR EXCLUSIONS:

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

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 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))

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, physical therapist, 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

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.

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 clinician 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. 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 for a BMI outside normal parameters 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 for a BMI outside normal parameters 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)

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

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

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

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

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

Performance Not Met: BMI documented outside 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 (1).”

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 (7). 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 (8).

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 of weight loss is associated with a significant risk reduction for diabetes and CVD (9). 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 (10). There is also evidence that high-intensity behavioral counseling is effective, whether delivered in-person, by phone, or electronically (11). 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 (12). 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 (13). 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 (14).

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 (15).

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 (CI) = 1.78, 2.90 (16). Individuals with a BMI < 18.5kg/m2 have been shown to be at a higher risk for adverse events, postoperative infection, and/or mortality following a surgical procedure (17, 18, 19, 20). BMI below normal parameters is a risk factor for developing severe illness from respiratory infections such as influenza and COVID19 (21, 22). BMI below normal parameters can negatively impact both male and female fertility (23, 24).

Poor nutrition or underlying health conditions can result in underweight (25). The National Health and Nutrition Examination Survey (NHANES) results from 2007-2010 indicate that women are more likely to be underweight than men (25). 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.

References

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. (2013). Prevention and management of obesity for adults. Bloomington, MN: Institute for Clinical Systems Improvement.
Flegal, K. M., Carroll, M. D., Kit, B. K., & Ogden, C. L. (2012). Prevalence of obesity and trends in the distribution of body mass index among U. S. adults, 1999-2010. JAMA, 307(5), 491-497. doi.10.1001/jama.2012.39
Ogden, C.L., Carroll, M.D., Fryar, C.D., Flegal, K.M. (2015). Prevalence of obesity among adults and youth: United States, 2011–2014. NCHS data brief, no 219. Hyattsville, MD: National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db219.pdf
Dong, Z., Xu, X., Wang, C., Cartledge, S., Maddison, R., & Mohammed Shariful Islam, S. (2020). Association of overweight and obesity with obstructive sleep apnoea: A systematic review and metaanalysis. Obesity Medicine, 17. doi: https://doi.org/10.1016/j.obmed.2020.100185
Hales, C. M., Carroll, M. D., Fryar, C. D., et al. (2017). Prevalence of obesity among adults and youth: United States, 2015-2016. NCHS Data Brief No. 288. https://www.cdc.gov/nchs/products/databriefs/db288.htm
Hales, C. M., Carroll, M. D., Fryar, C. D., & Ogden, C.L. (2020). Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017-2018. NCHS Data Brief No. 360. https://www.cdc.gov/nchs/products/databriefs/db360.htm
LeBlanc, E., O’Connor, E., Whitlock, E. P., Patnode, C., & Kapka, T. (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'
Barlow, S. E., & the Expert Committee. (2007). Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics, 120(Suppl. 4), S164-S192. doi:10.1542/peds.2007-2329C
Wadden, T. A, Butryn, M. L., & Wilson, C. (2007). Lifestyle modification for the management of obesity. Gastroenterology, 132 (6), 2226-2238. doi: 10.1053/j.gastro.2007.03.051
Wadden, T. A., Tronieri, J. S., & Butryn, M. L. (2020). Lifestyle modification approaches for the treatment of obesity in adults. American Psychologist, 75(2), 235–251
Tronieri, J. S., Wadden, T. A., Chao, A. M., & Tsai, A. G. (2019). Primary Care Interventions for Obesity: Review of the Evidence. Current obesity reports, 8(2), 128–136. https://doi.org/10.1007/s13679-019-00341-5
Raynor, H. A., & Champagne, C. M. (2016). Position of the Academy of Nutrition and Dietetics: Interventions for the treatment of overweight and obesity in adults. Journal of the Academy of Nutrition and Dietetics, 116(1), 129-147. doi:10.1016/jand.2015.10.031
Kraschnewski, J. L., Sciamanna, C. N., Stuckey, H. L., Chuang, C. H., Lehman, E. B., Hwang, K. O., Sherwood, L. L., & Nembhard, H. B. (2013). A silent response to the obesity epidemic: decline in US physician weight counseling. Medical care, 51(2), 186–192. https://doi.org/10.1097/MLR.0b013e3182726c33
Fitzpatrick, S. L., & Stevens, V. J. (2017). Adult obesity management in primary care, 2008-2013. Preventive medicine, 99, 128–133. https://doi.org/10.1016/j.ypmed.2017.02.020
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Katakam, A., Melnic, C. M., Bragdon, C. R., Sauder, N., Collins, A. K., & Bedair, H. S. (2021). Low body mass index is a predictor for mortality and increased length of stay following total joint arthroplasty. The Journal of Arthroplasty, 36(1), 72-77. https://doi.org/10.1016/j.arth.2020.07.055
Ottesen, T. D., Malpani, R., Galivanche, A. R., Zogg, C. K., Varthi, A. G., & Grauer, J. N. (2020). Underweight patients are at just as much risk as super morbidly obese patients when undergoing anterior cervical spine surgery. The Spine Journal: Official Journal of the North American Spine Society, 20(7), 1085- 1095. https://doi.org/10.1016/j.spinee.2020.03.007
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Rudasill, S. E., Dillon, D., Karunungan, K., Mardock, A. L., Hadaya, J., Sanaiha, Y., Tran, Z., & Benharash, P. (2021). The obesity paradox: Underweight patients are at the greatest risk of mortality after cholecystectomy. Surgery, 170(3), 675-681. https://doi.org/10.1016/j.surg.2021.03.034
Moser, J. S., Galindo-Fraga, A., Ortiz-Hernández, A. A., Gu, W., Hunsberger, S., Galán-Herrera, J. F., Guerrero, M. L., Ruiz-Palacios, G. M., Beigel, J. H., & La Red ILI 002 Study Group. (2019). Underweight, overweight, and obesity as independent risk factors for hospitalization in adults and children from influenza and other respiratory viruses. Influenza and Other Respiratory Viruses, 13(1), 3-9. https://doi.org/10.1111/irv.12618
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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 (1) (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 (1).

BMI cutoff point value of ≥ 23 kg/m2 should be used in the screening and confirmation of excess adiposity in Asian adults (1) (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) (1) (Grade A).

Behavioral lifestyle intervention should be tailored to a patient’s ethnic, cultural, socioeconomic, and educational background (1) (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) (2)

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” (3) (Evidence Category D). In addition, weight reduction prescriptions in older persons should be accompanied by proper nutritional counseling and regular body weight monitoring (3).

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 (3) (Evidence Category B).