In order for the Clinical Quality Measure report to generate, the following must be documented in the relevant patient's chart:

1.  The patient must be at least 18 years old or older at the start of the reporting period and have at least one face-to-face encounter with the provider during the reporting period.  

2.  Patient must also have a BMI recorded in the Vital Signs chart section.  The BMI must be recorded in the six months prior to the encounter date or during the reporting period.

3.  In addition, if the patient has an abnormal BMI*, there should be documentation to record if an adult weight screening and follow-up plan was performed.  Inserting the shortcut code, "PQRIbmi" in the encounter Plan field or Summary Interventions field will allow the user to select from a group of specific SMARText CPT codes that can be used to document for this measure.  

If the patient has an abnormal BMI*, the encounter Plan field or Summary Interventions field must include one of the following CPT codes:

(G8417, G8418 and S9470.  *Note: G8419, G8420, G8421 and G8422 will not increase the numerator).

*Abnormal BMI: Age 65 and older BMI >=30 or <22; age 18-64 BMI >=25 or <18.5.

*IMPORTANT NOTE: The SMARText Items that are in the PQRIbmi pick list may need to be re-downloaded due to some updates that were added in April of 2011.  To update your SMARText Items go to Docutainers > SMARText Items and click on the light bulb button to update your local SMARText Items. DO NOT update your SMARText Items during clinic hours (this will slow your SOAPware system down considerably).  You should update SMARText Items overnight or through the weekend when the clinic is closed.

Eligible Providers will be required to report two population criteria for this Clinical Quality Measure.

Population Criteria #1: 65 Years and Older

Numerator Calculation:  

The numerator for this measurement is calculated based on the following:

1.  The number of patients in the denominator that have a normal BMI (BMI >= 22 or <30) OR an abnormal BMI (BMI >= 30 or <22) recorded in the Vital Signs chart section (BMI must be recorded in the six months prior to the encounter date or during the reporting period);

2.  If the patient has an abnormal BMI, one of the following SMARText CPT codes must be documented in the Summary Interventions field or the SOAPnote Plan field:

• G8417: BMI above normal and a follow-up plan is documented
• G8418: BMI below normal and a follow-up plan is documented
• S9470: Referral - Dietitian

The following codes will not increase the numerator:

• G8419: BMI out of normal range - NO follow-up plan documented & BMI in normal range and documented, no f/u needed
• G8420: BMI in normal range and documented, no f/u needed
• G8421: BMI-NOT calculated (and/or out of range); No documented plan, No reason specified
• G8422: Patient not eligible for BMI calculation for medical reasons

Denominator Calculation:

The denominator for this measurement is calculated based on the following:

1.  The number of patients that were at least 65 years of age and older by the start of the reporting period and have at least one face-to-face encounter with the provider during the reporting period.

Population Criteria #2: 18 Years to 64 Years Old

Numerator Calculation:  

The numerator for this measurement is calculated based on the following:

1.  The number of patients in the denominator that have a normal BMI (BMI >=18.5 or <25) OR an abnormal BMI (BMI >=25 or <18.5) recorded in the Vital Signs chart section (BMI must be recorded in the six months prior to the encounter date or during the reporting period);

2.  If the patient has an abnormal BMI, one of the following SMARText CPT codes must be documented in the Summary Interventions field or the SOAPnote Plan field:

• G8417: BMI above normal and a follow-up plan is documented
• G8418: BMI below normal and a follow-up plan is documented
• S9470: Referral - Dietitian

The following codes will not increase the numerator:

• G8419: BMI out of normal range - NO follow-up plan documented & BMI in normal range and documented, no f/u needed
• G8420: BMI in normal range and documented, no f/u needed
• G8421: BMI-NOT calculated (and/or out of range); No documented plan, No reason specified
• G8422: Patient not eligible for BMI calculation for medical reasons

Denominator Calculation:

The denominator for this measurement is calculated based on the following:

1.  The number of patients that were between the ages of 18 years and 64 years of age by the start of the reporting period and have at least one face-to-face encounter with the provider during the reporting period.

All of the items listed in the above steps need to be documented as structured data (as detailed above) in order to allow the user to capture the numerator, denominator and percentage for this quality measure.  

For information on how to export the numerator, denominator and percentage for each Clinical Quality Measure, click here.

For more information on reporting clinical quality measures, click here.

When an Eligible Provider attests on NQF 0421 they will be required to report on two population criteria, which requires entering two sets of numerators and denominators.

SOAPware will export the Clinical Quality Measure report in XML format.  The XML for NQF 0421 contains the following information:

Population Criteria 1

• Providers NPI Number for Numerator 1
• Selected Reporting Period
• CQM or PQRI number
• Eligible Instances/Denominator for Population Criteria 1
• Meets Performance Instances/Numerator for Population Criteria 1
• Reporting Rate
• Performance Rate for Population Criteria 1 (the Numerator 1 divided by the Denominator 1)

Population Criteria 2

• Providers NPI Number for Numerator 2
• Selected Reporting Period
• CQM or PQRI number
• Eligible Instances/Denominator for Population Criteria 2
• Meets Performance Instances/Numerator for Population Criteria 2
• Reporting Rate
• Performance Rate for Population Criteria 2 (the Numerator 2 divided by the Denominator 2)

Please see the above screenshot for a visual explanation of how to read the XML document.  The above screenshot can be resized for easier viewing (simply click on the picture to view a larger version).