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

General eCQM Information

CMS Measure ID CMS22v10
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 elevated 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 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)
Domain Community/Population Health
Measure Scoring Proportion
Measure Type Process
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 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

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

Release Notes

Header

  • Updated the eCQM version number.

    Measure Section: eCQM Version Number

    Source of Change: Annual Update

  • Updated Measure Developer.

    Measure Section: Measure Developer

    Source of Change: Measure Lead

  • Replaced 'pre-hypertensive' with 'elevated' to reflect updated blood pressure classifications in the most recent American College of Cardiology (ACC) and American Heart Association (AHA) Guidelines.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated the Rationale section to incorporate language reflecting ACC/AHA guidelines stressing the importance of periodic blood pressure screening to preventing cardiovascular disease risk, and evidence from the peer-reviewed literature indicating potential for improved blood pressure levels following pharmacist-led interventions involving medication counseling and patient education.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Annual Update

  • Updated blood pressure readings indicating elevated and hypertensive thresholds and recommended follow-up interventions per the 2017 ACC/AHA guidelines.

    Measure Section: Definition

    Source of Change: Measure Lead

  • Added clarifying language to guidance section indicating that the measure is not eligible for telehealth visits.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Added clarifying language to guidance section of episode-based measures to define the episode.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Replaced 'pre-hypertensive' with 'elevated' to reflect updated blood pressure classifications per the 2017 ACC/AHA guidelines.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Updated systolic and diastolic blood pressure (SBP and DBP) values for Encounters with Normal (SBP less than 120 mmHg and DBP less than 80 mmHg) and Elevated (SBP 120 to 129 mmHg and DBP less than 80 mmHg), First (SBP greater than or equal to 130 mmHg or DBP greater than or equal to 80 mmHg), and Second (SBP 130 to 139 mmHg or DBP 80 to 89 mmHg or SBP greater than or equal to 140 mmHg or DBP greater than or equal to 90 mmHG) Hypertensive Readings per the 2017 ACC/AHA guidelines.

    Measure Section: Numerator

    Source of Change: Expert Work Group Review

  • Linked denominator exception 'patient reason' to appropriate blood pressure classifications and recommended follow up plans defined in the numerator. Clinicians will only meet the exception criteria if the documentation reflects that the patient declined one of the follow up interventions that is appropriate based on the patient's BP at that encounter.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

  • Added denominator exceptions for patients declining interventions for encounters with elevated or first or second hypertensive readings.

    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 blood pressure values for Encounters with Elevated, First, and Second Hypertensive readings and recommended follow-up interventions associated with each threshold to align with the 2017 ACC/AHA guidelines. There are two sets of follow-up interventions for the SBP and DBP thresholds given for Encounters with Second Hypertensive Readings.

    Measure Section: Multiple Sections

    Source of Change: Expert Work Group Review

  • 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

  • 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

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 Weight Reduction Recommended (2.16.840.1.113883.3.600.1510): Added 6 SNOMED CT codes (1181000175107, 284352003, 388975008, 398752005, 410201001, 445033007) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Dietary Recommendations (2.16.840.1.113883.3.600.1515): Added 6 SNOMED CT codes (1151000175103, 285383009, 435771000124106, 699849008, 715282001, 770749002) based on review by technical experts, SMEs, and/or public feedback. Deleted 4 SNOMED CT codes (289177005, 437211000124103, 437391000124102, 438961000124108) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Encounter to Screen for Blood Pressure (2.16.840.1.113883.3.600.1920): Deleted 1 CPT code (99201) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Diagnosis of Hypertension (2.16.840.1.113883.3.600.263): Deleted 1 ICD-10-CM code (I67.4) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Pharmacologic Therapy for Hypertension (2.16.840.1.113883.3.526.1577): Deleted 33 RxNorm codes based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Referral to Primary Care or Alternate Provider (2.16.840.1.113883.3.526.3.1580): Added 2 SNOMED CT codes (306362008, 453641000124107) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Removed value set Follow Up Within One Year (2.16.840.1.113883.3.526.3.1579) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added direct reference codes SNOMED CT codes (183624006, 183625007) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jul 08, 2021