| Measure Information | 2021 Performance Period |
|---|---|
| CMS eCQM ID | CMS22v9 |
| NQF Number | Not Applicable |
| MIPS Quality ID | 317 |
| Description |
Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is pre-hypertensive or hypertensive |
| Initial Population |
All patient visits for patients aged 18 years and older at the beginning of the measurement period |
| Numerator |
Patient visits where patients 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 |
Equals Initial Population |
| Denominator Exclusions |
Patient has an active diagnosis of hypertension |
| Denominator Exceptions |
Documentation of medical reason(s) for not screening for high blood pressure (e.g., 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). Documentation of patient reason(s) for not screening for blood pressure measurements or for not ordering an appropriate follow-up intervention if patient is pre-hypertensive or hypertensive (e.g., patient refuses). |
| Steward | Centers for Medicare & Medicaid Services (CMS) |
| Measure Scoring | Proportion measure |
| Measure Type | Process measure |
| Improvement Notation |
Higher score indicates better quality |
| Guidance |
This eCQM is an episode-based measure and should be reported at every visit for patients aged 18 years and older. This measure will be calculated based upon the clinical actions performed at every visit during the measurement period for each patient. The measure requires that blood pressure measurements (i.e., diastolic and systolic) be obtained during each visit in order to determine the blood pressure reading used to evaluate if an intervention is needed. Both the systolic and diastolic blood pressure measurements are required for inclusion. If there are multiple blood pressures obtained during a patient visit, only the last, or most recent, pressure measurement will be used to evaluate the measure requirements. 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 blood pressure reading as indicated, example: "Patient referred to primary care provider for BP management." This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
| Telehealth Eligible | No |
| Next Version | |
| Previous Version | No Version Available |
Compare eCQM Versions
The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.
Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.
| Measure Information | 2021 Performance Period | 2022 Performance Period | 2023 Performance Period | 2024 Performance Period |
|---|---|---|---|---|
| Title | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented |
| CMS eCQM ID | CMS22v9 | CMS22v10 | CMS22v11 | CMS22v12 |
| NQF Number | Not Applicable | Not Applicable | Not Applicable | Not Applicable |
| Description |
Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is pre-hypertensive or hypertensive |
Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is elevated or hypertensive |
Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is elevated or hypertensive |
Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is elevated or hypertensive |
| Initial Population |
All patient visits for patients aged 18 years and older at the beginning of the measurement period |
All patient visits for patients aged 18 years and older at the beginning of the measurement period |
All patient visits for patients aged 18 years and older at the beginning of the measurement period |
All patient visits for patients aged 18 years and older at the beginning of the measurement period |
| Denominator |
Equals Initial Population |
Equals Initial Population |
Equals Initial Population |
Equals Initial Population |
| Denominator Exclusions | Patient has an active diagnosis of hypertension | Patient has an active diagnosis of hypertension | Patient has an active diagnosis of hypertension | Patient has an active diagnosis of hypertension |
| Numerator |
Patient visits where patients 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 |
Patient visits where patients were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated, if the blood pressure is elevated or hypertensive |
Patient visits where patients were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated, if the blood pressure is elevated or hypertensive |
Patient visits where patients were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated, if the blood pressure is elevated or hypertensive |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
Not Applicable |
| Denominator Exceptions |
Documentation of medical reason(s) for not screening for high blood pressure (e.g., 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). Documentation of patient reason(s) for not screening for blood pressure measurements or for not ordering an appropriate follow-up intervention if patient is pre-hypertensive or hypertensive (e.g., patient refuses). |
Documentation of medical reason(s) for not screening for high blood pressure (e.g., 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). Documentation of patient reason(s) for not screening for blood pressure measurements or for not ordering an appropriate follow-up intervention if patient BP is elevated or hypertensive (e.g., patient refuses). |
Documentation of medical reason(s) for not screening for high blood pressure (e.g., 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). Documentation of patient reason(s) for not screening for blood pressure measurements or for not ordering an appropriate follow-up intervention if patient BP is elevated or hypertensive (e.g., patient refuses). |
Documentation of medical reason(s) for not screening for high blood pressure (e.g., 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). Documentation of patient reason(s) for not screening for blood pressure measurements or for not ordering an appropriate follow-up intervention if patient BP is elevated or hypertensive (e.g., patient refuses). |
| Measure Steward | Centers for Medicare & Medicaid Services (CMS) | Centers for Medicare & Medicaid Services (CMS) | Centers for Medicare & Medicaid Services (CMS) | Centers for Medicare & Medicaid Services (CMS) |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process measure | Process measure | Process measure | Process measure |
| Improvement Notation |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
Higher score indicates better quality |
| Guidance |
This eCQM is an episode-based measure and should be reported at every visit for patients aged 18 years and older. This measure will be calculated based upon the clinical actions performed at every visit during the measurement period for each patient. The measure requires that blood pressure measurements (i.e., diastolic and systolic) be obtained during each visit in order to determine the blood pressure reading used to evaluate if an intervention is needed. Both the systolic and diastolic blood pressure measurements are required for inclusion. If there are multiple blood pressures obtained during a patient visit, only the last, or most recent, pressure measurement will be used to evaluate the measure requirements. 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 blood pressure reading as indicated, example: "Patient referred to primary care provider for BP management." This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients aged 18 years and older during the measurement period. This measure should be reported for every visit. The measure requires that blood pressure measurements (i.e., diastolic and systolic) be obtained during each visit in order to determine the blood pressure reading used to evaluate if an intervention is needed. Both the systolic and diastolic blood pressure measurements are required for inclusion. If there are multiple blood pressures obtained during a patient visit, only the last, or most recent, pressure measurement will be used to evaluate the measure requirements. 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 blood pressure reading as indicated, example: "Patient referred to primary care provider for BP management." Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients aged 18 years and older during the measurement period. This measure should be reported for every visit. The measure requires that blood pressure measurements (i.e., diastolic and systolic) be obtained during each visit in order to determine the blood pressure reading used to evaluate if an intervention is needed. Both the systolic and diastolic blood pressure measurements are required for inclusion. If there are multiple blood pressures obtained during a patient visit, only the last, or most recent, pressure measurement will be used to evaluate the measure requirements. 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 blood pressure reading as indicated, example: "Patient referred to primary care provider for BP management." Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
This eCQM is an episode-based measure. An episode is defined as each eligible encounter for patients aged 18 years and older during the measurement period. This measure should be reported for every visit. The measure requires that blood pressure measurements (i.e., diastolic and systolic) be obtained during each visit in order to determine the blood pressure reading used to evaluate if an intervention is needed. Both the systolic and diastolic blood pressure measurements are required for inclusion. If there are multiple blood pressures obtained during a patient visit, only the last, or most recent, pressure measurement will be used to evaluate the measure requirements. 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 blood pressure reading as indicated, example: "Patient referred to primary care provider for BP management." Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| MIPS Quality ID | 317 | 317 | 317 | 317 |
| Telehealth Eligible | No | No | No | No |
| Next Version | CMS22v10 | CMS22v11 | CMS22v12 | No Version Available |
| Previous Version | No Version Available |
Data Element Repository
Header
-
Updated eCQM Version Number.
Measure Section: eCQM Version Number
Source of Change: Standards Update
-
Updated the measure developer field.
Measure Section: Measure Developer
Source of Change: Measure Lead
-
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
-
Updated disclaimer.
Measure Section: Disclaimer
Source of Change: Standards Update
-
Updated rationale citations to align with American Psychological Association (APA) formatting.
Measure Section: Rationale
Source of Change: Measure Lead
-
Updated references to align with APA formatting.
Measure Section: Reference
Source of Change: Measure Lead
-
Added text to indicate whether the measure is patient-based or episode-based.
Measure Section: Guidance
Source of Change: Standards Update
-
Added text to identify the Quality Data Model (QDM) version used in the measure specification.
Measure Section: Guidance
Source of Change: Standards Update
-
Revised denominator exception language to follow a similar format as other eCQMs.
Measure Section: Denominator Exceptions
Source of Change: Measure Lead
-
Revised the measure language to reflect a change from a patient-based measure to an episode-based measure, requiring the measure be evaluated at every patient visit during the measurement period.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Logic
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Revised the timing of the denominator exclusion to align with the measure language and ensure that only patients who have an active diagnosis of hypertension (i.e., if the diagnosis has an end date, it is not before the start of the visit) are excluded from the denominator.
Measure Section: Denominator Exclusions
Source of Change: ONC Project Tracking System (Jira): CQM-3723
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Revised the Clinical Quality Language (CQL) definition and logic structure to reflect a change from a patient-based measure to an episode-based measure, requiring the measure be evaluated at every patient visit during the measurement period.
Measure Section: Multiple Sections
Source of Change: Measure Lead
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Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000). Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.
Measure Section: Multiple Sections
Source of Change: Standards Update
-
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section: Multiple Sections
Source of Change: Standards Update
-
Updated CQL expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).
Measure Section: Multiple Sections
Source of Change: Standards Update
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QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.
Measure Section: Multiple Sections
Source of Change: Standards Update
-
Updated CQL definition names and aliases used to more closely align with clinical concept intent or create consistency of naming across measures.
Measure Section: Multiple Sections
Source of Change: Measure Lead
-
Revised CQL definition construction to reduce the overall complexity of the measure logic without changing the intent and/or application of data element. These revisions were intended to make the definition logic less complex, easier to understand, and more meaningful.
Measure Section: Multiple Sections
Source of Change: Measure Lead
-
Revised measure timings to improve alignment with the intent of the measure requirements.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Value set
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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Replaced value set ECG 12 lead or study order (2.16.840.1.113883.3.600.2448) with direct reference codes LOINC codes (34534-8, 11524-6) to align with best practices for replacing single code value sets with direct reference codes.
Measure Section: Terminology
Source of Change: Measure Lead
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Removed ICD-9-CM extensional value sets from applicable groupings due to ICD-9-CM no longer being maintained and the measure not requiring historical lookback period.
Measure Section: Terminology
Source of Change: Measure Lead
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Replaced SNOMED CT value set Referral to Alternative Provider / Primary Care Provider (2.16.840.1.113883.3.600.1475) with grouping value set Referral to Primary Care or Alternate Provider (2.16.840.1.113883.3.526.3.1580) to align with best practices, based on expert review and/or public feedback.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Dietary Recommendations (2.16.840.1.113883.3.600.1515): Deleted 1 ICD-9-CM code (V65.3).Removed ICD-9 codes from all measures that do not have lookback periods or removed ICD-9 codes from all measures with lookback period for which the ICD-9 codes were no longer relevant.
Measure Section: Terminology
Source of Change: Annual Update
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Value set (2.16.840.1.113883.3.600.1518): Renamed to Recommendation to Increase Physical Activity to align with best practices, based on expert review and/or public feedback.
Measure Section: Terminology
Source of Change: Annual Update
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Replaced SNOMED CT value set Follow up within 4 weeks (2.16.840.1.113883.3.600.1537) with grouping value set Follow Up Within 4 Weeks (2.16.840.1.113883.3.526.3.1578) to align with best practices, based on expert review and/or public feedback.
Measure Section: Terminology
Source of Change: Annual Update
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Replaced SNOMED CT value set Follow up within one year (2.16.840.1.113883.3.600.1474) with grouping value set Follow Up Within One Year (2.16.840.1.113883.3.526.3.1579) to align with best practices, based on expert review and/or public feedback.
Measure Section: Terminology
Source of Change: Annual Update
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Value set (2.16.840.1.113883.3.600.1920): Renamed to Encounter to Screen for Blood Pressure to align with best practices, based on expert review and/or public feedback.
Measure Section: Terminology
Source of Change: Annual Update
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Value set (2.16.840.1.113883.3.600.263): Renamed to Diagnosis of Hypertension to align with best practices, based on expert review and/or public feedback.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Diagnosis of Hypertension (2.16.840.1.113883.3.600.263): Deleted 14 SNOMED CT codes due to intent of the data element. Added 14 ICD-10-CM codes to align with other terminologies' value set content for same data element and deleted 4 ICD-10-CM codes (H35.039, I16.0, I16.1, I16.9) due to detail of coding practices.
Measure Section: Terminology
Source of Change: Annual Update
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Replaced SNOMED CT value set Anti-Hypertensive Pharmacologic Therapy (2.16.840.1.113883.3.600.1476) with grouping value set Pharmacologic Therapy for Hypertension (2.16.840.1.113883.3.526.3.1577) to align with best practices, based on expert review and/or public feedback.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Pharmacologic Therapy for Hypertension (2.16.840.1.113883.3.600.1476): Added 26 RxNorm codes and deleted 24 RxNorm codes based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Finding of Elevated Blood Pressure or Hypertension (2.16.840.1.113762.1.4.1047.514): Deleted 4 SNOMED CT codes (163028000, 170581003, 170582005, 38936003) that do not align with data element intent.
Measure Section: Terminology
Source of Change: Annual Update
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Replaced SNOMED CT value set Moderation of ETOH Consumption Recommendation (2.16.840.1.113883.3.600.823) with grouping value set Referral or Counseling for Alcohol Consumption (2.16.840.1.113883.3.526.3.1583) to align with best practices, based on expert review and/or public feedback.
Measure Section: Terminology
Source of Change: Annual Update
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Replaced SNOMED CT value set Lifestyle Recommendation (2.16.840.1.113883.3.600.1508) with grouping value set Lifestyle Recommendation (2.16.840.1.113883.3.526.3.1581) to align with best practices, based on expert review and/or public feedback.
Measure Section: Terminology
Source of Change: Annual Update
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Replaced value set Medical or Other Reason Not Done (2.16.840.1.113883.3.600.1.1502) with value set Medical Reason (2.16.840.1.113883.3.526.3.1007) for harmonization purposes, based on expert review and/or public feedback.
Measure Section: Terminology
Source of Change: Annual Update
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Replaced SNOMED CT value set Patient Reason refused (2.16.840.1.113883.3.600.791) with grouping value set Patient Declined (2.16.840.1.113883.3.526.3.1582) to align with best practices, based on expert review and/or public feedback.
Measure Section: Terminology
Source of Change: Annual Update