General eCQM Information
| CMS Measure ID | CMS22v7 |
|---|---|
| NQF Number | None |
| Measure Description |
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated |
| Initial Population | All patients aged 18 years and older at the beginning of the measurement period with at least one eligible encounter during the measurement period |
| Denominator Statement |
Equals Initial Population |
| Denominator Exclusions |
Patient has an active diagnosis of hypertension |
| Numerator Statement |
Patients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated if the blood pressure is pre-hypertensive or hypertensive |
| Numerator Exclusions |
Not Applicable |
| Denominator Exceptions |
Patient Reason(s): Patient refuses to participate (either BP measurement or follow-up) OR Medical Reason(s): Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient's health status. This may include but is not limited to severely elevated BP when immediate medical treatment is indicated. |
| Measure Steward | Centers for Medicare & Medicaid Services (CMS) |
| Domain | Community/Population Health |
| Measure Scoring | Proportion measure |
| Measure Type | Process measure |
| Improvement Notation |
Higher score indicates better quality |
| Guidance |
Both the systolic and diastolic blood pressure measurements are required for inclusion. If there are multiple blood pressures on the same date of service, use the most recent as the representative blood pressure. Eligible professionals or eligible clinicians who report the measure must perform the blood pressure screening at the time of a qualifying visit by an eligible professional or eligible clinician and may not obtain measurements from external sources. The intent of this measure is to screen patients for high blood pressure and provide recommended follow-up as indicated. The documented follow-up plan must be related to the current BP reading as indicated, example: "Patient referred to primary care provider for BP management." |
| Quality ID | 317 |
| Meaningful Measure | Preventive Care |
| Next Version |
Data Element Repository
Header
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Updated Version Number.
Measure Section: eMeasure Version number
Source of Change: Measure Lead
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Updated Copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Updated Disclaimer.
Measure Section: Disclaimer
Source of Change: Measure Lead
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Replaced 'Before the beginning of' with 'at the beginning of' to align with CQL logic.
Measure Section: Initial Population
Source of Change: Measure Lead
Logic
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Additional timing attributes were added to most datatypes in QDM 5.3 to facilitate accurate retrieval of time related information within CQL logic. Timing attributes now include a time interval, such as prevalence period or relevant period, and/or actual time of documentation with Author Datetime. Relevant period is the general method to describe start and stop times for datatypes. Prevalence period is used for some datatypes to more accurately define onset and abatement times.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Cardinality was assigned to each attribute to be more explicit in guiding specification and implementation of QDM data elements. Cardinality refers to the number of instances of the attribute that can be included in the measure description. Cardinality for most attributes is 0.. 1 (i.e., can occur up to 1 time), but some attributes have a cardinality of 0.. * (i.e., can occur multiple times).
Measure Section: Multiple Sections
Source of Change: Standards Update
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CQL libraries contain sets of CQL definitions, or CQL expression statements. A context statement, patient or population, can now be used in a CQL library to clearly establish how the subsequent list of CQL expressions will be interpreted. A 'Population' context will interpret the CQL expression with reference to the entire population of the item being counted, patients or encounters. A 'Patient' context will interpret the CQL expression with reference to a single patient. Context statements are not required, but one or more context statements may be used within a library to help clarify how the CQL expressions will be interpreted. Patient context is the default if none is specified.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Replaced measure-defined definitions with similar definitions and functions from CQL shared libraries for consistency across measures.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Updated measure logic from Quality Data Model (QDM)-based logic to Clinical Quality Language (CQL)-based logic. Information on CQL can be found at the eCQI Resource center (https://ecqi.healthit.gov/cql). Information about specific versions of the new standards in use for CMS reporting periods can be found at the eCQI Resource Center (https://ecqi.healthit.gov/ecqm-tools-key-resources). Switching from QDM to CQL brings with it many changes, as well as enhanced expression capability, but only those changes with significant impact will be outlined in technical release notes. For example, in the case of timing operators, changes may only be summarized if those changes impact the measure calculation.
Measure Section: Multiple Sections
Source of Change: Standards Update
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
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Value set BP Screening Encounter Codes (2.16.840.1.113883.3.600.1920): Added 5 CPT codes (99236, 99315, 99316, 99339, 99340).
Measure Section: QDM Data Elements
Source of Change: Annual Update
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Value set Anti-Hypertensive Pharmacologic Therapy (2.16.840.1.113883.3.600.1476): Deleted 2 RXNORM codes (247516, 901446).
Measure Section: QDM Data Elements
Source of Change: Annual Update
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Finding of Hypertension (2.16.840.1.113883.3.600.2395): Removed Finding of Hypertension.
Measure Section: QDM Data Elements
Source of Change: Annual Update
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Value set Payer (2.16.840.1.114222.4.11.3591): Added 11 SOP codes (299, 32127, 32128, 391, 517, 524, 614, 621, 622, 623, 629) and deleted 3 SOP codes (63, 64, 69).
Measure Section: QDM Data Elements
Source of Change: Annual Update
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Replaced LOINC single code value sets with direct referenced codes. A direct referenced code is a single concept code that is used to describe a clinical element directly within the logic. The use of direct referenced codes replaces the need for single code value sets. Measures using other code systems in single value sets may optionally transition to direct referenced codes.
Measure Section: QDM Data Elements
Source of Change: Standards Update
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Value set Payer (2.16.840.1.114222.4.11.3591): Deleted 1 SOP code (24).
Measure Section: QDM Data Elements
Source of Change: 2019 Addendum
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Value set Anti-Hypertensive Pharmacologic Therapy (2.16.840.1.113883.3.600.1476): Deleted 6 RXNORM codes (1009220, 1009247, 1009315, 1009320, 197497, 310139).
Measure Section: QDM Data Elements
Source of Change: 2019 Addendum