Thank you for the question regarding CMS69v12: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan. The measure requires that an intervention is based on a documented out of range BMI. As stated in the Guidance section of the measure specifications: “The documented follow-up plan must be based on the documented BMI, outside of normal parameters, example: ‘Patient referred to nutrition counseling for BMI above or below normal parameters.’”

For measure compliance, are provider notes on BMI follow up required to directly relate the follow up, for example exercise or nutrition counseling, to BMI? For example, a patient has high BMI, diabetes, heart disease. Follow up, per the provider note is "exercise and nutrition counseling." This counseling would have an impact on all three diagnoses. The provider may not always note that the exercise and nutrition counseling was for out-of-range BMI because it pertains to more than the patient's BMI. However, the counseling took place at an appointment where high BMI was noted and discussed. Would this counseling still qualify as follow up even though the provider did not specifically write "counseled for nutrition and exercise due to high BMI" and they instead wrote "counseled for nutrition and exercise" or "discussed nutrition and exercise" ? Thank you for your time.