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Controlling High Blood Pressure

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
Quality Domain Effective Clinical Care
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 (https://ecqi.healthit.gov/qdm) for more information on the QDM.

MIPS Quality ID 236
Meaningful Measure Management of Chronic Conditions
Telehealth Eligible Yes
Next Version
Previous Version

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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
Quality Domain Effective Clinical Care Effective Clinical Care Effective Clinical Care
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 (https://ecqi.healthit.gov/qdm) 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
Meaningful Measure Management of Chronic Conditions Management of Chronic Conditions Management of Chronic Conditions
Telehealth Eligible Yes Yes Yes
Next Version CMS165v10 CMS165v11 No Version Available
Previous Version No Version Available

Release Notes

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

Last Updated: May 04, 2022