Controlling High Blood Pressure | eCQI Resource Center

Measure Information	2022 Performance Period
CMS eCQM ID	CMS165v10
NQF Number	Not Applicable
Description	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
Initial Population	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.
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 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.
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 Exceptions	None
Measure 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. 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.
MIPS Quality ID	236
Telehealth Eligible	Yes
Next Version	CMS165v11
Previous Version	CMS165v9

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Measure Information	2021 Performance Period	2022 Performance Period	2023 Performance Period
Title	Controlling High Blood Pressure	Controlling High Blood Pressure	Controlling High Blood Pressure
CMS eCQM ID	CMS165v9	CMS165v10	CMS165v11
NQF Number	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
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
Denominator	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.
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
Numerator Exclusions	Not Applicable	Not Applicable	Not Applicable
Denominator Exceptions	None	None	None
Measure Steward	National Committee for Quality Assurance	National Committee for Quality Assurance	National Committee for Quality Assurance
Measure Scoring	Proportion measure	Proportion measure	Proportion measure
Measure Type	Intermediate Outcome measure	Intermediate Outcome measure	Intermediate Clinical Outcome measure
Improvement Notation	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.
MIPS Quality ID	236	236	236
Telehealth Eligible	Yes	Yes	Yes
Next Version	CMS165v10	CMS165v11	No Version Available
Previous Version	No Version Available	CMS165v9	CMS165v10

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CMS165v10-TRN.xlsx	20.87 KB

Data Element Repository

Data Elements contained within CMS165v10

Value Sets

Value Sets to be used with CMS165v10

Release Notes

CMS165v10-TRN.xlsx

Header

Updated the eCQM version number.

Measure Section: eCQM Version Number

Source of Change: Annual Update
Updated the measure description to align with the measure intent and guidance.

Measure Section: Description

Source of Change: Measure Lead
Updated copyright.

Measure Section: Copyright

Source of Change: Annual Update
Updated the rationale to align with current evidence.

Measure Section: Rationale

Source of Change: Measure Lead
Updated references.

Measure Section: Reference

Source of Change: Annual Update
Revised the guidance language to further clarify the measure intent.

Measure Section: Guidance

Source of Change: Measure Lead
Updated the Denominator Exclusions to add an exclusion for palliative care.

Measure Section: Denominator Exclusions

Source of Change: Measure Lead
Revised the advanced illness and frailty denominator exclusion to clarify the intent of the exclusion criteria.

Measure Section: Denominator Exclusions

Source of Change: Measure Lead
Replaced 'overlaps' or 'overlapping' in the denominator exclusions with plain language to clarify the measure intent.

Measure Section: Denominator Exclusions

Source of Change: Measure Lead
Revised the timing associated with the essential hypertension diagnosis within the narrative to align with the measure intent.

Measure Section: Multiple Sections

Source of Change: Measure Lead

Logic

Added online assessments and telephone visits as appropriate encounters based on the increased use of telehealth services.

Measure Section: Initial Population

Source of Change: Measure Lead
Removed comments from the 'Qualifying Diastolic Blood Pressure Reading' and 'Qualifying Systolic Blood Pressure Reading'definitions to streamline the logic.

Measure Section: Definitions

Source of Change: Measure Lead
Updated the names of Clinical Quality Language (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 the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.

Measure Section: Multiple Sections

Source of Change: Standards Update
Updated Denominator Exclusions definition and added PalliativeCare.Palliative Care in the Measurement Period definition to add an exclusion for palliative care.

Measure Section: Multiple Sections

Source of Change: Measure Lead
Revised the advanced illness and frailty denominator exclusion to align with the header and adhere to QDMv5.5 standards.

Measure Section: Multiple Sections

Source of Change: Measure Lead
Removed the Vascular Access for Dialysis value set from the Renal Procedures definition to streamline existing value sets and reduce redundancies.

Measure Section: Multiple Sections

Source of Change: Measure Lead
Revised the timing associated with the essential hypertension diagnosis in the Essential Hypertension Diagnosis definition to align with the measure intent.

Measure Section: Multiple Sections

Source of Change: Measure Lead
Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.

Measure Section: Multiple Sections

Source of Change: Standards Update
Revised the timing of the ESRD encounter in the End Stage Renal Disease Encounter definition to align with the measure intent and to capture encounters on the last day of the measurement period.

Measure Section: Multiple Sections

Source of Change: Measure Lead
Update Adult Outpatient Encounters CQL library to 2.0.000.

Measure Section: Multiple Sections

Source of Change: Measure Lead
Updated Advanced Illness and Frailty Exclusions CQL Library to version 6.0.000.

Measure Section: Multiple Sections

Source of Change: Measure Lead
Updated Hospice CQL Library to version 3.0.000.

Measure Section: Multiple Sections

Source of Change: Measure Lead
Added PalliativeCareExclusion CQL library version 1.0.000.

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.

Removed value set Vascular Access for Dialysis (2.16.840.1.113883.3.464.1003.109.12.1011) based on change in measure requirements/measure specification.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Pregnancy (2.16.840.1.113883.3.526.3.378): Added 77 ICD-10-CM codes based on review by technical experts, SMEs, and/or public feedback. Deleted 19 ICD-10-CM codes based on review by technical experts, SMEs, and/or public feedback. Deleted 24 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Dialysis Services (2.16.840.1.113883.3.464.1003.109.12.1013): Added 3 CPT codes (99512, 90997, 90999) based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations. Deleted 5 CPT codes (1019320, 90940, 90957, 90958, 90959) based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations. Added 1 HCPCS code (S9339) based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Essential Hypertension (2.16.840.1.113883.3.464.1003.104.12.1011): Added 2 SNOMED CT codes (1078301000112109, 461301000124109) based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Kidney Transplant (2.16.840.1.113883.3.464.1003.109.12.1012): Added 13 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 35 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 4 CPT codes (50300, 50320, 50340, 50370) based on review by technical experts, SMEs, and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Advanced Illness (2.16.840.1.113883.3.464.1003.110.12.1082): Added 34 ICD-10-CM codes based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations or terminology updates. Added 179 SNOMED CT codes based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations, and based on terminology updates.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Outpatient (2.16.840.1.113883.3.464.1003.101.12.1087): Added 11 SNOMED CT codes (185463005, 185464004, 185465003, 281036007, 30346009, 37894004, 3391000175108, 439740005, 77406008, 444971000124105, 84251009) based on review by technical experts, SMEs, and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Frailty Device (2.16.840.1.113883.3.464.1003.118.12.1300): Added 124 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 22 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Frailty Encounter (2.16.840.1.113883.3.464.1003.101.12.1088): Deleted 1 SNOMED CT code (413467001) based on review by technical experts, SMEs, and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Frailty Symptom (2.16.840.1.113883.3.464.1003.113.12.1075): Added 13 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 69 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Frailty Diagnosis (2.16.840.1.113883.3.464.1003.113.12.1074): Added 14 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 13 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Added 166 ICD-10-CM codes based on review by technical experts, SMEs, and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Dementia Medications (2.16.840.1.113883.3.464.1003.196.12.1510): Added 4 RxNorm codes (1599803, 1599805, 1805420, 1805425) based on change in measure requirements/measure specification. Deleted 3 RxNorm codes (1858970, 996572, 996624) based on change in measure requirements/measure specification.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Acute Inpatient (2.16.840.1.113883.3.464.1003.101.12.1083): Added 10 SNOMED CT codes (10378005, 18083007, 183452005, 19951005, 2252009, 73607007, 305339001, 50699000, 74857009, 78680009) based on updated evidence in published guidelines, published literature, or from published specialty medical society or group recommendations.

Measure Section: Terminology

Source of Change: Measure Lead
Added value set Palliative Care Encounter (2.16.840.1.113883.3.464.1003.101.12.1090) based on change in measure requirements/measure specification.

Measure Section: Terminology

Source of Change: Measure Lead
Added value set Palliative Care Intervention (2.16.840.1.113883.3.464.1003.198.12.1135) based on change in measure requirements/measure specification.

Measure Section: Terminology

Source of Change: Measure Lead
Added value set Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080) based on change in measure requirements/measure specification.

Measure Section: Terminology

Source of Change: Measure Lead
Added value set Online Assessment (2.16.840.1.113883.3.464.1003.101.12.1089) based on change in measure requirements/measure specification.

Measure Section: Terminology

Source of Change: Measure Lead
Replaced value set ED (2.16.840.1.113883.3.464.1003.101.12.1085) with value set Emergency Department Visit (2.16.840.1.113883.3.464.1003.101.12.1010) based on review by technical experts, SMEs, and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead
Added direct reference code LOINC code (71007-9) based on change in measure requirements/measure specification.

Measure Section: Terminology

Source of Change: Measure Lead