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Measure 128


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

Description: The percentage of adult patients seen in the previous year with a BMI outside of normal parameters who are provided with a follow-up plan.

Measure ID: 128

Type: Process

CMS Derm Specialty Set: No

Priority: No

Topped out: Yes for Claims

Reporting methods: Registry/QCDR, EHR, or Claims

Maximum points: 10

Measure purpose: This measure encourages physicians to measure patient BMI and create follow-up plans for treatment when the BMI is outside of normal parameters. 

Calculation

The numerator: The number of patient encounters in which the physician measures patient BMI and creates a follow-up plan for treatment when the BMI is outside of normal parameters

÷

The denominator: All patients aged 18 and older with at least one eligible encounter during the reporting period.

Measure calculation example

Dr. Nguyen saw 179 patients aged 18 or older during the reporting period. There were no exclusions. This is the denominator.

Dr. Nguyen measured BMI, and when the BMI is outside of normal parameters documents a follow-up plan, for 132 patients. This is the numerator.

Quality of patient care = 132/179. Dr. Nguyen has a score of 73.7% for this measure. This translates to 4.0 to 4.9 points when reporting by registry.

Important note

Because of how this measure is structured, physicians score 3 points even if they report on only one patient. Physicians receive no additional score for reporting scores that fall below 34.35%. For example, if Dr. Nguyen reported on one patient encounter he would earn 3 points. Unfortunately, a score of 99.9% earns 8.9 points, while a score of 100% earns 10 points. In effect, there is a gap in earned points between a nearly perfect score and a perfect score.


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Quality measure score benchmark

CMS will award points based on a comparison of your performance rate to CMS benchmarks listed below. Reach the performance rate listed to achieve the corresponding points per measure. Points achieved for the Quality category will account for 45% of the overall MIPS score.

Benchmarks for registry submissions

The table below shows CMS benchmarks for registry submissions. 

Below 3 Decile 3Decile 4
Decile 5Decile 6Decile 7Decile 8Decile 9Decile 10
Performance rate  1 patient  34.35 - 
54.25
 54.26- 
74.56
74.57 - 
90.59
90.60 - 
97.55
97.56 - 
99.86
 99.87- 
99.99
- 100
Points  3 points  3 - 3.9  4 - 4.9 5 - 5.9 6 - 6.9 7 - 7.9 8 - 8.9 9 - 9.9 10
Benchmarks for EHR submissions

The table below shows CMS benchmarks for EHR submissions. 

Below 3Decile 3
Decile 4
Decile 5Decile 6
Decile 7
Decile 8
Decile 9
Performance rate  1 patient  21.15 - 
24.58
 24.59- 
28.51
28.52 - 
34.20
34.21 - 
43.84
43.85 - 
60.30
 60.31- 
78.24
78.25 - 
93.28
>= 
93.29 
Points  3 points  3 - 3.9  4 - 4.9 5 - 5.9 6 - 6.9 7 - 7.9 8 - 8.9 9 - 9.9 10
Benchmarks for claims submissions

The table below shows CMS benchmarks for claims submissions. 

Below 3
Decile 3
Decile 4
Decile 5Decile 6Decile 7Decile 8Decile 9Decile 10
Performance rate  1 patient  37.52 - 
47.77
47.78 - 
74.47
74.48 - 
95.19
95.20 - 
99.26
99.27 - 
99.99
 --  --  100.00 
Points  3 points  3 - 3.9  4 - 4.9 5 - 5.9 6 - 6.9 7 - 7.9 8 - 8.9 9 - 9.9 10

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