Measure 128: Body Mass Index (BMI) Screening and Follow-Up (SOAP 2.0)
This is a guide for 2.0 measure reporting. For 1.0 measure reporting, click here.
BMI numbers outside of normal parameters are determined to population health, regardless of whether the patient is above or below the expected range. Screening for BMI and follow-up, therefore, contributes to quality goals of population health and cost reduction.
Who can report this measure?
PTs and OTs can report this measure.
- Patient age (18 or older)
- BMI ≥ 18.5 and < 25 kg/m2
- Visit type: Initial Evaluation
Do I have to report on this measure for every visit?
Reporting is once per performance period. If more than one BMI is submitted during the measurement period, then the most recent BMI will be used to determine if the performance has been met.
Eligible Procedure Codes
PT: 97161, 97162, 97163
OT: 97165, 97166, 97167
- Patient height and weight (measured by staff; self-reporting values not allowed)
- Patient BMI
- If the BMI is below or above normal for the patient’s age, then you must have a follow-up plan that includes details regarding one or more of the following options:
- Education – counseling you provided regarding weight management and/or resources available to the individual for further education.
- Referral to a Registered Dietitian Nutritionist (RDN), exercise physiologist, mental health professional, or surgeon, for lifestyle/behavior therapy
- Referral to primary care provider – specific physician referred to.
- Dietary supplements
- Exercise counseling
- Nutrition counseling
For more information on Measure 128, please see the Measure Specification Guide.
Measure Reporting in the WebPT EMR
- Click the MIPS badge in the Case Summary to view the current Measure Status. Here you will see all measures that the patient is eligible for based on their Diagnoses and Procedure Code.
- On the Objective section, select the Body Measurements subsection to view and edit the required fields for Measure 128.
- Enter the patient’s Weight and Height. Remember, these must be measured in the clinic (not self-reported).
- The EMR will calculate the Body Mass Index automatically.
- Measure Met: If the patient is outside of the expected parameters, complete the Follow-up Plan field. This triggers a Measure Met indicator in the Measure Status column.
- When finished documenting, validate the selection in the Measure Status column.
- Excluded: Select the Excluded radio button if the patient meets any of the following reasons, then select the Reason in the required field:
- Patient refused measurement of height and/or weight
- Patient is currently pregnant
- Patient is receiving palliative or hospice care
- Other: Document reason(s) for not documenting height and/or weight
- Not Met: Select the Not Met radio button if the current list of medications are not documented as obtained, updated, or reviewed by the eligible clinician, reason not given.
- BMI is not documented and no reason is given
- BMI is documented outside of normal parameters, no follow-up plan is documented, and no reason is given
- If the note is signed without completing the required fields, an alert will appear. Required fields must be completed before submitting the note.