eCQM: Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (CMS 155v5)

eCQM:

Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents

CMS ID:

CMS 155v5

Measure Type:

Process

MIPS High Priority Measure:

No

Quality ID:

239

Eligible for Quality Programs:

  • Merit-Based Incentive Payment System (MIPS)
  • Medicaid EHR Incentive Program (Meaningful Use)

Performance Benchmark for MIPS:

34.95%

Description:

Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported.

  • Percentage of patients with height, weight, and body mass index (BMI) percentile documentation.
  • Percentage of patients with counseling for nutrition.
  • Percentage of patients with counseling for physical activity.

  • Numerator
    • Numerator 1: Patients who had a height, weight and body mass index (BMI) percentile recorded during the measurement period.

    • Numerator 2: Patients who had counseling for nutrition during a visit that occurs during the measurement period.

    • Numerator 3: Patients who had counseling for physical activity during a visit that occurs during the measurement period.

  • Denominator: Patients 3-17 years of age with at least one eligible outpatient visit (defined as a signed chart note with one of the following encounter types: Office Visit, Home Visit, Nurse Visit, or Nursing Home Visit) with a primary care physician (PCP) or an obstetrician/gynecologist (OB/GYN) during the measurement period.

    • Denominator Exclusion: Patients who have a diagnosis of pregnancy during the measurement period.

    • Denominator Exceptions: None

eCQM Patient Reports

eCQM Patient Reports can help you identify patient care gaps and improve the performance of your quality measures. Click on the blue result numbers in the eCQM Dashboard to see the patient report for this measure.

The eCQM Patient Reports list the individual patients included in the measure’s population, which measure cohorts the patient is in, and contact information for the patient to streamline any downstream communication that may be needed to fulfill the measure requirements. You can choose to print the patient list for a measure or export it as a CSV.

The measure cohorts included in the eCQM Patient Report for CMS 155v5 are:

  • Initial patient population
  • Denominator
  • Numerator
  • Exclusion

Practice Fusion Suggested Workflow
Practice Fusion suggests the following workflow to help ensure that you are able to meet the requirements of this measure within the Practice Fusion EHR.

  1. For all patients age 3-17 years, record their height and weight in the vitals flowsheet within the patient encounter (Numerator 1). Once entered, the BMI value and percentile will automatically calculate and can be viewed in the flowsheet or growth chart.

    1. For more information on documenting vitals in flowsheets, click here.

  2. When appropriate, document that counseling for nutrition was performed, using the suggested workflow in Table 3. (Numerator 2)

  3. When appropriate, document that counseling for physical activity was performed, using the suggested workflow in Table 3. (Numerator 3)

Table 3. Practice Fusion Suggested Workflow for Counseling for Nutrition

Type of counseling performed

Practice Fusion Suggested Workflow

Counseling for Nutrition

  • In the Screenings/Interventions/Assessments section of the encounter, search for the applicable nutrition counseling and select the item. Examples include:

    • Nutrition education (procedure) (SNOMED CT 61310001)

    • Diet education (procedure) (SNOMED CT 11816003)

    • Weight control education (procedure) (SNOMED CT 410200000)

  • Record and save the following information in the modal window that opens:

    • Status: Performed

    • Start Date: If the procedure was performed on the same date of service as the encounter in which it is recorded in the Screenings/Interventions/Assessments section, a start or end date should not be entered for the procedure. (See Graphic 1 for example.) 

Counseling for Physical Activity

  • In the Screenings/Interventions/Assessments section of the encounter, search for the applicable physical activity counseling and select the item. Examples include:

    • Exercise education (procedure) (SNOMED CT 304507003)

    • Recommendation regarding activity (procedure) (SNOMED CT 223415003)

    • Recommendation to exercise (procedure) (SNOMED CT 281090004)

  • Record and save the following information in the modal window that opens:

    • Status: Performed

    • Start Date: If the procedure was performed on the same date of service as the encounter in which it is recorded in the Screenings/Interventions/Assessments section, a start or end date should not be entered for the procedure. (See Graphic 1 for example.) 

Graphic 1: Example of data elements recorded in Screenings/Interventions/Assessments


To view a complete list of the applicable nutrition and physical activity recommendations that qualify for numerator credit, please
visit the United States Health Information Knowledgebase (USHIK). This site is produced by the Agency for Healthcare Research and Quality (AHRQ) in partnership with CMS and the National Library of Medicine (NLM). A free Unified Medical Language System® (UMLS) license, available from NLM, is required to access USHIK.

Additional Measure Information

  • To be recognized for the denominator exclusion, the patient must have a diagnosis of pregnancy during the measurement period recorded in his or her chart.
  • Because BMI norms for youth vary with age and sex, this measure evaluates whether BMI percentile is assessed rather than an absolute BMI value.

More Information

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