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

Measure Information	2023 Performance Period
CMS eCQM ID	CMS22v11
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 elevated 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 elevated 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 BP is elevated 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. 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.
Telehealth Eligible	No
Next Version	CMS22v12
Previous Version	CMS22v10

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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	CMS22v9	CMS22v10	CMS22v11

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Data Element Repository

Data Elements contained within CMS22v11

Value Sets

Value Sets to be used with CMS22v11

Release Notes

CMS22v11-TRN.xlsx

Header

Updated copyright.

Measure Section: Copyright

Source of Change: Annual Update
Updated disclaimer.

Measure Section: Disclaimer

Source of Change: Standards/Technical Update
Updated references.

Measure Section: Reference

Source of Change: Measure Lead
Clarified definition for second hypertensive blood pressure reading (Systolic Blood Pressure [SBP] 130-139 or Diastolic Blood Pressure [DBP] 80-89) to align with intent of measure.

Measure Section: Definition

Source of Change: ONC Project Tracking System (JIRA): CQM-5102
Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.

Measure Section: Guidance

Source of Change: Standards/Technical Update
Updated grammar, wording, and formatting to improve readability and consistency.

Measure Section: Multiple Sections

Source of Change: Measure Lead

Logic

Updated logic for second hypertensive blood pressure reading (SBP 130-139 or DBP 80-89) to align with intent of measure.

Measure Section: Definitions

Source of Change: ONC Project Tracking System (JIRA): CQM-5102
Revised logic of First Hypertensive (SBP >=130 OR DBP >= 80); Second Hypertensive (SBP >= 140 OR DBP >= 90); and Encounter with Elevated Blood Pressure Reading (SBP 120 to 129) and (DBP less than 80) to ensure values are captured for both diastolic and systolic blood pressure when evaluating criteria.

Measure Section: Definitions

Source of Change: Measure Lead
Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.

Measure Section: Multiple Sections

Source of Change: Standards/Technical Update
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.

Measure Section: Multiple Sections

Source of Change: Standards/Technical 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/Technical Update
Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.

Measure Section: Multiple Sections

Source of Change: Measure Lead
Updated logic using the new QDM 5.6 'Encounter, Performed' class attribute to exclude telehealth (or virtual) encounters using the logical representation (class !~ virtual), for measures containing telehealth-eligible codes, where telehealth is not appropriate. For more information, please refer to the 2023 Telehealth Guidance document.

Measure Section: Multiple Sections

Source of Change: Standards/Technical 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 Dietary Recommendations (2.16.840.1.113883.3.600.1515): Added 2 SNOMED CT codes (436691000124108, 436951000124105) based on terminology update. Deleted 5 SNOMED CT codes (182954008, 182955009, 182956005, 182960008, 361231003) based on terminology update.

Measure Section: Terminology

Source of Change: Annual Update
Value set Encounter to Screen for Blood Pressure (2.16.840.1.113883.3.600.1920): Added 1 CDT code (D3921) based on terminology update.

Measure Section: Terminology

Source of Change: Annual Update
Value set Pharmacologic Therapy for Hypertension (2.16.840.1.113883.3.526.1577): Added 4 RxNorm codes (2477889, 2047715, 2047716, 2047717) based on terminology update. Deleted 1 RxNorm code (1191185) based on terminology update.

Measure Section: Terminology

Source of Change: Annual Update
Value set Referral or Counseling for Alcohol Consumption (2.16.840.1.113883.3.526.3.1583): Added 16 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Weight Reduction Recommended (2.16.840.1.113883.3.600.1510): Added 8 SNOMED CT codes (307818003, 248114003, 289169006, 388962008, 388970003, 388976009, 410199003, 718361005) based on review by technical experts, SMEs, and/or public feedback. Added 7 HCPCS codes (S9452, S9470, S9451, G0270, G0271, G0447, G0473) based on review by technical experts, SMEs, and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Medical Reason (2.16.840.1.113883.3.526.3.1007): Deleted 1 SNOMED CT code (397745006) based on terminology update.

Measure Section: Terminology

Source of Change: Annual Update
Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead
Added direct reference code ActCode code (VR) based on review by technical experts, SMEs, and/or public feedback.

Measure Section: Terminology

Source of Change: Measure Lead