download chevron-down chevron-right chevron-with-circle-down chevron-with-circle-up check circle-with-minus circle-with-plus export help-with-circle inbox link mail old-phone star-outlined star user v-card close close close Back to top
Top

Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

CMS Measure ID
CMS22v8
Version
8
NQF Number
Not Applicable
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
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.

Previous Version
Measure Scoring
Measure Type
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

Specifications

Attachment Size
CMS22v8.html 89.64 KB
CMS22v8.zip 87.62 KB
CMS22v8-TRN.xlsx 22.47 KB

Release Notes

 

Header

  • Updated eCQM version number.

    Measure Section: eCQM Version number

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

 

Logic

  • Added reason for referral 'Finding of Elevated Blood Pressure or Hypertension' to the CQL definition 'Referral to Alternate Provider' to reflect intended functionality and correct a prior logic omission. This logic change includes the addition of a new value set Finding of Elevated Blood Pressure or Hypertension (2.16.840.1.113762.1.4.1047.514).

    Measure Section: Numerator

    Source of Change: ONC Project Tracking System (JIRA): CQM-3129

  • Added 'exists' to CQL definitions 'Follow Up One Year' and 'Hypertensive Interventions at Most Recent Blood Pressure Encounter' to clarify the logic and reflect intended functionality; to return a true/false value rather than a potential list of interventions.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Removed 'exists' and/or 'is not null' from definitions 'Has First Hypertensive Reading With Interventions,' 'Has Prehypertensive Reading With Interventions,' and 'Has Second Hypertensive Reading With Intervention' to clarify the logic and reflect intended functionality; removing the possibility of meeting the numerator criteria without fulfilling all of the intended conditions.

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (JIRA): CQM-3546

  • Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with CQL Style Guide.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MAT) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

 

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • ​Removed code system versions from direct reference codes. Please refer to Appendix A of the Electronic Clinical Quality Measure Logic and Implementation Guidance document for a list of code system versions used in the eCQM specifications for 2020 reporting/performance.

    Measure Section: Terminology

    Source of Change: Standards Update

  • Standardized purpose statement language in value sets across eCQMs. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Anti-Hypertensive Pharmacologic Therapy (2.16.840.1.113883.3.600.1476): Added 8 RxNorm codes (197956, 197958, 199797, 199798, 199799, 353386, 353387, 827073) and deleted 4 RxNorm codes (858593, 885880, 897719, 904561).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set BP Screening Encounter Codes (2.16.840.1.113883.3.600.1920): Deleted 2 SNOMED CT codes (30346009, 37894004). Added 7 CDT codes (D7111, D7220, D7230, D7240, D7241, D7250, D7251).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Diagnosis of hypertension (2.16.840.1.113883.3.600.263): Deleted 1 SNOMED CT code (185717000).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Dietary Recommendations (2.16.840.1.113883.3.600.1515): Added 7 SNOMED CT codes (289176001, 289177005, 437211000124103, 437231000124109, 437391000124102, 437421000124105, 438961000124108).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Finding of Elevated Blood Pressure or Hypertension (2.16.840.1.113762.1.4.1047.514): Added Finding of Elevated Blood Pressure or Hypertension grouping value set, including SNOMED CT extensional value set (2.16.840.1.113762.1.4.1047.513), ICD-10-CM extensional value set (2.16.840.1.113762.1.4.1047.512), and SNOMED CT extensional value set (2.16.840.1.113883.3.600.2395). This grouping value set is used to define a reason for referral (attribute) in the Clinical Quality Language (CQL) logic.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (JIRA): CQM-3129

  • Value set Physical Activity Recommendation (2.16.840.1.113883.3.600.1518): Deleted ICD-9-CM extensional value set (2.16.840.1.113883.3.600.1517), including 1 ICD-9-CM code (V65.41).

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: Jul 30, 2019