Hypertension: Improvement in Blood Pressure

Last updated: May 3, 2018

CMS Measure ID: CMS65v7
Version: 7
NQF Number: None
Measure Description:

Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period

Initial Patient Population:

All patients aged 18-85 years of age, who had at least one outpatient visit in the first six months of the measurement year, who have a diagnosis of essential hypertension documented during that outpatient visit, and who have uncontrolled baseline blood pressure at the time of that visit

Denominator Statement:

Equals Initial Population

Denominator Exclusions:

Exclude from the denominator all patients with evidence of end-stage renal disease (ESRD) on or prior to December 31 of the measurement year. Documentation of dialysis or kidney transplant also meets the criteria for evidence of ESRD.

Exclude from the denominator all patients with a diagnosis of pregnancy during the measurement year.

Exclude patients who were in hospice care during the measurement year.

Numerator Statement:

Patients whose follow-up blood pressure is at least 10 mmHg less than their baseline blood pressure or is adequately controlled.

If a follow-up blood pressure reading is not recorded during the measurement year, the patient's blood pressure is assumed not improved.

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: Centers for Medicare and Medicaid Services (CMS)
Domain: Effective Clinical Care
Next Version:
Previous Version:
Improvement Notation:

A higher score indicates better quality

Guidance:

Blood pressure readings must be taken while the patient is sitting. If multiple measurements occur on the same date, the last systolic and diastolic readings should be used.

Occurrence A of Physical Exam, Performed: Systolic Blood Pressure (result) represents the baseline blood pressure, which must occur prior to Occurrence B of Physical Exam, Performed: Systolic Blood Pressure (result), which represents the follow-up blood pressure.

To calculate the Physical Exam, Performed: Delta systolic blood pressure (result) data element, subtract the value of Occurrence B of Physical Exam, Performed: Systolic Blood Pressure (result) from the value of Occurrence A of Physical Exam, Performed: Systolic Blood Pressure (result).

The data element Physical Exam, Performed: Delta systolic blood pressure (result) is intended to represent the result of the mathematic comparison between systolic blood pressures taken during two separate visits. This is a calculation artifact, and there's no requirement to document the delta data element in the medical record.

Notes: Value Set content updated Sept 2017

Specifications

Release Notes

Header

  • ​Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • ​Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​Updated Disclaimer.

    Measure Section: Disclaimer

    Source of Change: Measure Lead

  • ​Updated the exclusion statement in the header to exclude patients in hospice care from the Denominator. Measures that focus on screenings and procedures may not be appropriate or a priority for those who are at end of life (ie, on hospice).

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

Logic

  • Replaced the 'starts before start of' and 'starts before end of' logical operator to address situations where time stamps are not attached to procedures, diagnosis, and immunizations. Wherever applicable, the operators have been changed to 'starts before or concurrent with start of' or 'starts before or concurrent with end of' respectively.

    Measure Section: Initial Population

    Source of Change: JIRA (CQM-1936)

  • Added new lines of logic to the Denominator Exclusions for all NCQA-stewarded measures (except CMS82) to ensure patients in hospice care are excluded from the Denominator.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated the Numerator logic to state that the delta systolic blood pressure should be greater than or equal to 10 mm Hg to meet the measure intent.

    Measure Section: Numerator

    Source of Change: JIRA (CQM-1940)

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 Kidney Transplant (2.16.840.1.113883.3.464.1003.109.12.1012): Deleted 1 SNOMEDCT code (48994000).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Pregnancy (2.16.840.1.113883.3.526.3.378): Deleted 550 ICD9CM codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Encounter Inpatient (2.16.840.1.113883.3.666.5.307): Added Encounter Inpatient.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Hospice care ambulatory (2.16.840.1.113762.1.4.1108.15): Added Hospice care ambulatory.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Discharged to Health Care Facility for Hospice Care (2.16.840.1.113883.3.117.1.7.1.207): Added Discharged to Health Care Facility for Hospice Care.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Discharged to Home for Hospice Care (2.16.840.1.113883.3.117.1.7.1.209): Added Discharged to Home for Hospice Care.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Pregnancy (2.16.840.1.113883.3.526.3.378): Added 12 ICD10CM codes.

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

External Resources