Controlling High Blood Pressure

Last updated: October 25, 2017

CMS Measure ID: CMS165v6
Version: 6
NQF Number: 0018
Measure Description:

Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period

Initial Patient Population:

Patients 18-85 years of age who had a diagnosis of essential hypertension within the first six months of the measurement period or any time prior to the measurement period

Denominator Statement:

Equals Initial Population

Denominator Exclusions:

Patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period. Also, exclude patients with a diagnosis of pregnancy during the measurement period.

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

Numerator Statement:

Patients whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: National Committee for Quality Assurance
Domain: Effective Clinical Care
Previous Version: Controlling High Blood Pressure
Improvement Notation:

Higher score indicates better quality

Guidance:

In reference to the numerator element, only blood pressure readings performed by a clinician in the provider office are acceptable for numerator compliance with this measure. Blood pressure readings from the patient's home (including readings directly from monitoring devices) are not acceptable.

If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed not controlled.

If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading.

Addendum 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 References.

    Measure Section: Reference

    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

  • Removed 'Other Services Related to Dialysis' and 'Dialysis Education' interventions from the list of Denominator Exclusions to remove proxies for dialysis.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated the logic to ensure the BP reading takes place after the diagnosis of essential hypertension to meet the measure intent.

    Measure Section: Numerator

    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.

  • 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 Dialysis Education (2.16.840.1.113883.3.464.1003.109.12.1016): Removed Dialysis Education.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Other Services Related to Dialysis (2.16.840.1.113883.3.464.1003.109.12.1015): Removed Other Services Related to Dialysis.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Dialysis Services (2.16.840.1.113883.3.464.1003.109.12.1013): Added 1 SNOMEDCT code (714749008).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set ESRD Monthly Outpatient Services (2.16.840.1.113883.3.464.1003.109.12.1014): Added 10 CPT codes (90951, 90952, 90953, 90954, 90955, 90956, 90963, 90964, 90967, 90968).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

  • 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