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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
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

Denominator

Equals Initial Population

Denominator Exclusions

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 elevated or hypertensive

Numerator Exclusions

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 BP is elevated or hypertensive (e.g., patient refuses).

Measure Steward Centers for Medicare & Medicaid Services (CMS)
Quality Domain Community/Population Health
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.

MIPS Quality ID 317
Meaningful Measure Preventive Care
Telehealth Eligible No
Next Version No Version Available
Previous Version

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Measure Information 2021 Performance Period 2022 Performance Period 2023 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
CMS eCQM ID CMS22v9 CMS22v10 CMS22v11
NQF Number 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

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

Denominator

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
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

Numerator Exclusions

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).

Measure Steward Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS)
Quality Domain Community/Population Health Community/Population Health Community/Population Health
Measure Scoring Proportion measure Proportion measure Proportion measure
Measure Type Process measure Process measure Process measure
Improvement Notation

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 (https://ecqi.healthit.gov/qdm) 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
Meaningful Measure Preventive Care Preventive Care Preventive Care
Telehealth Eligible No No No
Next Version CMS22v10 CMS22v11 No Version Available
Previous Version No Version Available

Release Notes

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

Last Updated: Aug 29, 2022