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

General eCQM Information

CMS Measure ID CMS22v9
NQF Number Not Applicable
Measure 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

Initial Population All patient visits for patients aged 18 years and older at the beginning of the measurement period
Denominator Statement

Equals Initial Population

Denominator Exclusions

Patient has an active diagnosis of hypertension

Numerator Statement

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

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 is pre-hypertensive or hypertensive (e.g., patient refuses).

Measure Steward Centers for Medicare & Medicaid Services (CMS)
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 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.

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

Release Notes

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Updated the measure developer field.

    Measure Section: Measure Developer

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated disclaimer.

    Measure Section: Disclaimer

    Source of Change: Standards Update

  • Updated rationale citations to align with American Psychological Association (APA) formatting.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated references to align with APA formatting.

    Measure Section: Reference

    Source of Change: Measure Lead

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

    Measure Section: Guidance

    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

  • Revised denominator exception language to follow a similar format as other eCQMs.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

  • Revised the measure language to reflect a change from a patient-based measure to an episode-based measure, requiring the measure be evaluated at every patient visit during the measurement period.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Revised the timing of the denominator exclusion to align with the measure language and ensure that only patients who have an active diagnosis of hypertension (i.e., if the diagnosis has an end date, it is not before the start of the visit) are excluded from the denominator.

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (Jira): CQM-3723

  • Revised the Clinical Quality Language (CQL) definition and logic structure to reflect a change from a patient-based measure to an episode-based measure, requiring the measure be evaluated at every patient visit during the measurement period.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • 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

  • 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 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

  • 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 definition names and aliases used to more closely align with clinical concept intent or create consistency of naming across measures.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Revised CQL definition construction to reduce the overall complexity of the measure logic without changing the intent and/or application of data element. These revisions were intended to make the definition logic less complex, easier to understand, and more meaningful.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Revised measure timings to improve alignment with the intent of the measure requirements.

    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.

  • Replaced value set ECG 12 lead or study order (2.16.840.1.113883.3.600.2448) with direct reference codes LOINC codes (34534-8, 11524-6) to align with best practices for replacing single code value sets with direct reference codes.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Removed ICD-9-CM extensional value sets from applicable groupings due to ICD-9-CM no longer being maintained and the measure not requiring historical lookback period.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced SNOMED CT value set Referral to Alternative Provider / Primary Care Provider (2.16.840.1.113883.3.600.1475) with grouping value set Referral to Primary Care or Alternate Provider (2.16.840.1.113883.3.526.3.1580) to align with best practices, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Dietary Recommendations (2.16.840.1.113883.3.600.1515): Deleted 1 ICD-9-CM code (V65.3).Removed ICD-9 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

  • Value set (2.16.840.1.113883.3.600.1518): Renamed to Recommendation to Increase Physical Activity to align with best practices, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced SNOMED CT value set Follow up within 4 weeks (2.16.840.1.113883.3.600.1537) with grouping value set Follow Up Within 4 Weeks (2.16.840.1.113883.3.526.3.1578) to align with best practices, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced SNOMED CT value set Follow up within one year (2.16.840.1.113883.3.600.1474) with grouping value set Follow Up Within One Year (2.16.840.1.113883.3.526.3.1579) to align with best practices, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.600.1920): Renamed to Encounter to Screen for Blood Pressure to align with best practices, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.600.263): Renamed to Diagnosis of Hypertension to align with best practices, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Diagnosis of Hypertension (2.16.840.1.113883.3.600.263): Deleted 14 SNOMED CT codes due to intent of the data element. Added 14 ICD-10-CM codes to align with other terminologies' value set content for same data element and deleted 4 ICD-10-CM codes (H35.039, I16.0, I16.1, I16.9) due to detail of coding practices.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced SNOMED CT value set Anti-Hypertensive Pharmacologic Therapy (2.16.840.1.113883.3.600.1476) with grouping value set Pharmacologic Therapy for Hypertension (2.16.840.1.113883.3.526.3.1577) to align with best practices, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Pharmacologic Therapy for Hypertension (2.16.840.1.113883.3.600.1476): Added 26 RxNorm codes and deleted 24 RxNorm codes based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Finding of Elevated Blood Pressure or Hypertension (2.16.840.1.113762.1.4.1047.514): Deleted 4 SNOMED CT codes (163028000, 170581003, 170582005, 38936003) that do not align with data element intent.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced SNOMED CT value set Moderation of ETOH Consumption Recommendation (2.16.840.1.113883.3.600.823) with grouping value set Referral or Counseling for Alcohol Consumption (2.16.840.1.113883.3.526.3.1583) to align with best practices, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced SNOMED CT value set Lifestyle Recommendation (2.16.840.1.113883.3.600.1508) with grouping value set Lifestyle Recommendation (2.16.840.1.113883.3.526.3.1581) to align with best practices, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced value set Medical or Other Reason Not Done (2.16.840.1.113883.3.600.1.1502) with value set Medical Reason (2.16.840.1.113883.3.526.3.1007) for harmonization purposes, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced SNOMED CT value set Patient Reason refused (2.16.840.1.113883.3.600.791) with grouping value set Patient Declined (2.16.840.1.113883.3.526.3.1582) to align with best practices, based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: Dec 18, 2020