Controlling High Blood Pressure | eCQI Resource Center

Measure Information	2021 Performance Period
CMS eCQM ID	CMS165v9
NQF Number	Not Applicable
MIPS Quality ID	236
Description	Percentage of patients 18-85 years of age who had a diagnosis of hypertension overlapping the measurement period or the year prior to the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period
Initial Population	Patients 18-85 years of age who had a visit and diagnosis of essential hypertension overlapping the measurement period or the year prior to the measurement period
Numerator	Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period
Numerator Exclusions	Not Applicable
Denominator	Equals Initial Population
Denominator Exclusions	Patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period. Also exclude patients with a diagnosis of pregnancy during the measurement period. Exclude patients whose hospice care overlaps the measurement period. Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period. Exclude patients 66 and older with advanced illness and frailty because it is unlikely that patients will benefit from the services being measured.
Denominator Exceptions	None
Steward	National Committee for Quality Assurance
Measure Scoring	Proportion measure
Measure Type	Intermediate Outcome measure
Improvement Notation	Higher score indicates better quality
Guidance	In reference to the numerator element, only blood pressure readings performed by a clinician or a remote monitoring device are acceptable for numerator compliance with this measure. Do not include BP readings: -Taken during an acute inpatient stay or an ED visit -Taken on the same day as a diagnostic test or diagnostic or therapeutic procedure that requires a change in diet or change in medication on or one day before the day of the test or procedure, with the exception of fasting blood tests. -Reported by or taken by the member If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled." If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading. This eCQM is a patient-based measure. 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	Yes
Next Version	CMS165v10
Previous Version	No Version Available

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Measure Information	2021 Performance Period	2022 Performance Period	2023 Performance Period	2024 Performance Period
Title	Controlling High Blood Pressure	Controlling High Blood Pressure	Controlling High Blood Pressure	Controlling High Blood Pressure
CMS eCQM ID	CMS165v9	CMS165v10	CMS165v11	CMS165v12
NQF Number	Not Applicable	Not Applicable	Not Applicable	Not Applicable
Description	Percentage of patients 18-85 years of age who had a diagnosis of hypertension overlapping the measurement period or the year prior to the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period	Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period	Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period	Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90 mmHg) during the measurement period
Initial Population	Patients 18-85 years of age who had a visit and diagnosis of essential hypertension overlapping the measurement period or the year prior to the measurement period	Patients 18-85 years of age who had a visit and diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period.	Patients 18-85 years of age by the end of the measurement period who had a visit and diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period	Patients 18-85 years of age by the end of the measurement period who had a visit during the measurement period and diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period
Denominator	Equals Initial Population	Equals Initial Population	Equals Initial Population	Equals Initial Population
Denominator Exclusions	Patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period. Also exclude patients with a diagnosis of pregnancy during the measurement period. Exclude patients whose hospice care overlaps the measurement period. Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period. Exclude patients 66 and older with advanced illness and frailty because it is unlikely that patients will benefit from the services being measured.	Patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period. Also exclude patients with a diagnosis of pregnancy during the measurement period. Exclude patients who are in hospice care for any part of the measurement period. Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period. Exclude patients 66 and older with an indication of frailty for any part of the measurement period who meet any of the following criteria: - Advanced illness with two outpatient encounters during the measurement period or the year prior - OR advanced illness with one inpatient encounter during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior Exclude patients 81 and older with an indication of frailty for any part of the measurement period. Exclude patients receiving palliative care during the measurement period.	Patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period. Also exclude patients with a diagnosis of pregnancy during the measurement period. Exclude patients who are in hospice care for any part of the measurement period. Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period. Exclude patients 66-80 by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria: - Advanced illness with two outpatient encounters during the measurement period or the year prior - OR advanced illness with one inpatient encounter during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior Exclude patients 81 and older by the end of the measurement period with an indication of frailty for any part of the measurement period. Exclude patients receiving palliative care for any part of the measurement period.	Patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period. Also exclude patients with a diagnosis of pregnancy during the measurement period. Exclude patients who are in hospice care for any part of the measurement period. Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period. Exclude patients 66-80 by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria: - Advanced illness with two outpatient encounters during the measurement period or the year prior - OR advanced illness with one inpatient encounter during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior Exclude patients 81 and older by the end of the measurement period with an indication of frailty for any part of the measurement period. Exclude patients receiving palliative care for any part of the measurement period.
Numerator	Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period	Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period	Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period	Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period
Numerator Exclusions	Not Applicable	Not Applicable	Not Applicable	Not Applicable
Denominator Exceptions	None	None	None	None
Measure Steward	National Committee for Quality Assurance	National Committee for Quality Assurance	National Committee for Quality Assurance	National Committee for Quality Assurance
Measure Scoring	Proportion measure	Proportion measure	Proportion measure	Proportion measure
Measure Type	Intermediate Outcome measure	Intermediate Outcome measure	Intermediate Clinical Outcome measure	Intermediate Clinical Outcome measure
Improvement Notation	Higher score indicates better quality	Higher score indicates better quality	Higher score indicates better quality	Higher score indicates better quality
Guidance	In reference to the numerator element, only blood pressure readings performed by a clinician or a remote monitoring device are acceptable for numerator compliance with this measure. Do not include BP readings: -Taken during an acute inpatient stay or an ED visit -Taken on the same day as a diagnostic test or diagnostic or therapeutic procedure that requires a change in diet or change in medication on or one day before the day of the test or procedure, with the exception of fasting blood tests. -Reported by or taken by the member If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled." If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.	In reference to the numerator element, only blood pressure readings performed by a clinician or a remote monitoring device are acceptable for numerator compliance with this measure. This includes blood pressures taken in person by a clinician and blood pressures measured remotely by electronic monitoring devices capable of transmitting the blood pressure data to the clinician. Blood pressure readings taken by a remote monitoring device and conveyed by the patient to the clinician are also acceptable. It is the clinician’s responsibility and discretion to confirm the remote monitoring device used to obtain the blood pressure is considered acceptable and reliable and whether the blood pressure reading is considered accurate before documenting it in the patient’s medical record. Do not include BP readings: -Taken during an acute inpatient stay or an ED visit -Taken on the same day as a diagnostic test or diagnostic or therapeutic procedure that requires a change in diet or change in medication on or one day before the day of the test or procedure, with the exception of fasting blood tests. -Taken by the patient using a non-digital device such as with a manual blood pressure cuff and a stethoscope. If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled." If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.	In reference to the numerator element, only blood pressure readings performed by a clinician or a remote monitoring device are acceptable for numerator compliance with this measure. This includes blood pressures taken in person by a clinician and blood pressures measured remotely by electronic monitoring devices capable of transmitting the blood pressure data to the clinician. Blood pressure readings taken by a remote monitoring device and conveyed by the patient to the clinician are also acceptable. It is the clinician’s responsibility and discretion to confirm the remote monitoring device used to obtain the blood pressure is considered acceptable and reliable and whether the blood pressure reading is considered accurate before documenting it in the patient’s medical record. Do not include BP readings taken during an acute inpatient stay or an ED visit. If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled". If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading. Ranges and thresholds do not meet criteria for this measure. A distinct numeric result for both the systolic and diastolic BP reading is required for numerator compliance. This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.	In reference to the numerator element, only blood pressure readings performed by a clinician or an automated blood pressure monitor or device are acceptable for numerator compliance with this measure. This includes blood pressures taken in person by a clinician and blood pressures measured remotely by electronic monitoring devices capable of transmitting the blood pressure data to the clinician. Blood pressure readings taken by an automated blood pressure monitor or device and conveyed by the patient to the clinician are also acceptable. It is the clinician’s responsibility and discretion to confirm the automated blood pressure monitor or device used to obtain the blood pressure is considered acceptable and reliable and whether the blood pressure reading is considered accurate before documenting it in the patient’s medical record. Do not include BP readings taken during an acute inpatient stay or an ED visit. If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled". If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading. Ranges and thresholds do not meet criteria for this measure. A distinct numeric result for both the systolic and diastolic BP reading is required for numerator compliance. This eCQM is a patient-based measure. 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	236	236	236	236
Telehealth Eligible	Yes	Yes	Yes	Yes
Next Version	CMS165v10	CMS165v11	CMS165v12	No Version Available
Previous Version	No Version Available	CMS165v9	CMS165v10	CMS165v11

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Data Element Repository

Data Elements contained within CMS165v9

Value Sets

Value Sets to be used with CMS165v9

Release Notes

CMS165v9-TRN.xlsx

Header

Updated eCQM Version Number.

Measure Section: eCQM Version Number

Source of Change: Standards Update
Updated copyright.

Measure Section: Copyright

Source of Change: Annual Update
Updated the rationale to remove outdated references and content and to update references.

Measure Section: Rationale

Source of Change: Measure Lead
Updated the clinical recommendations statement to remove outdated references and update with the most recent clinical recommendations.

Measure Section: Clinical Recommendation Statement

Source of Change: Measure Lead
Updated references.

Measure Section: Reference

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
Added text to indicate whether the measure is patient-based or episode-based.

Measure Section: Guidance

Source of Change: Standards Update
Updated denominator exclusions to add the word 'consecutive' to clarify that the Long-Term Illness (LTI) exclusion should be for 90 consecutive days.

Measure Section: Denominator Exclusions

Source of Change: Measure Lead

Logic

Updated denominator exclusion logic for frailty and clarified that the long-term illness exclusion should be for 90 'consecutive' days to reduce ambiguity.

Measure Section: Denominator Exclusions

Source of Change: Measure Lead
Revised the 'Essential Hypertension Diagnosis' definition logic to ensure alignment between the logic, header and measure intent.

Measure Section: Definitions

Source of Change: ONC Project Tracking System (Jira): CQM-3816
Clinical Quality Language (CQL) Library version update: Updated version number of the Adult_Outpatient_Encounters Library (Adult_Outpatient_Encounters-1.3.000).

Measure Section: Multiple Sections

Source of Change: Measure Lead
CQL Library version update: Updated version number of the Hospice Library (Hospice-2.2.000).

Measure Section: Multiple Sections

Source of Change: Measure Lead
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 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
Updated CQL Library version number of the advanced illness and frailty exclusion library (AdvancedIllnessandFrailtyExclusionECQM-5.5.000).

Measure Section: Multiple Sections

Source of Change: Measure Lead
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 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

Value Set

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

Value set Vascular Access for Dialysis (2.16.840.1.113883.3.464.1003.109.12.1011): Deleted 2 CPT codes (36147, 36148) based on terminology update.

Measure Section: Terminology

Source of Change: Annual Update
Value set End Stage Renal Disease (2.16.840.1.113883.3.526.3.353): Deleted 1 ICD-9-CM code (585.6) based on terminology update.

Measure Section: Terminology

Source of Change: Annual Update
Value set Pregnancy (2.16.840.1.113883.3.526.3.378): Added 53 SNOMED CT codes based on terminology update and deleted 1 SNOMED CT code (199715003) based on expert review and/or public feedback. Added 2 ICD-10-CM codes (O00.00, O00.01) based on terminology update.

Measure Section: Terminology

Source of Change: Annual Update
Value set Frailty Symptom (2.16.840.1.113883.3.464.1003.113.12.1075): Deleted 4 SNOMED CT codes (267031002, 272060000, 272062008, 314109004) based on terminology update.

Measure Section: Terminology

Source of Change: Annual Update
Value set Nursing Facility Visit (2.16.840.1.113883.3.464.1003.101.12.1012): Added 3 CPT codes (99315, 99316, 99318) based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations, to capture additional nursing facility visit encounter types.

Measure Section: Terminology

Source of Change: Annual Update
Value set Frailty Device (2.16.840.1.113883.3.464.1003.118.12.1300): Removed extensional value set Frailty Device (2.16.840.1.113883.3.464.1003.118.11.1114) with HCPCS codes from the grouping and added Frailty Device SNOMED (2.16.840.1.113883.3.464.1003.118.11.1220) with SNOMED CT codes to the grouping to align with recommended terminology.

Measure Section: Terminology

Source of Change: Annual Update
Value Set Dialysis Services (2.16.840.1.113883.3.464.1003.109.12.1013): Deleted 4 CPT codes (90920, 90921, 90924, 90925) based on terminology update.

Measure Section: Terminology

Source of Change: Annual Update
Value set Acute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1083): Deleted 1 SNOMED CT code (2876009) based on terminology update.

Measure Section: Terminology

Source of Change: Annual Update
Vale set Chronic Kidney Disease, Stage 5 (2.16.840.1.113883.3.526.3.1002): Deleted 1 ICD-9-CM code (585.5). Removed ICD-9-CM 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