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

Last updated: September 14, 2018

CMS Measure ID: CMS22v7
Version: 7
NQF Number: None
Measure Description:

Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

Initial Patient Population:

All patients aged 18 years and older at the beginning of the measurement period with at least one eligible encounter during the measurement period

Denominator Statement:

Equals Initial Populationinfo-icon

Denominator Exclusions:

Patient has an active diagnosis of hypertension

Numerator Statement:

Patients who 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:

Patient Reason(s):

Patient refuses to participate (either BP measurement or follow-up)

OR

Medical Reason(s):

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. This may include but is not limited to severely elevated BP when immediate medical treatment is indicated.

Measure Steward: Centers for Medicare & Medicaid Services (CMS)
Domain: Community/Population Health
Previous Version:
Improvement Notation:

Higher score indicates better quality

Guidance:

Both the systolic and diastolic blood pressure measurements are required for inclusion. If there are multiple blood pressures on the same date of service, use the most recent as the representative blood pressure.

Eligible professionalsinfo-icon or eligible cliniciansinfo-icon who report the measure must perform the blood pressure screening at the time of a qualifying visit by an eligible professionalinfo-icon or eligible clinicianinfo-icon and may not obtain measurements from external sources.

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 BP reading as indicated, example: Patient referred to primary care provider for BP management.

Quality ID: 317
Meaningful Measure: Preventive Care

Specifications

Release Notes

Header

  • Updated 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

  • Replaced 'Before the beginning of' with 'at the beginning of' to align with CQLinfo-icon logic.

    Measure Section: Initial Populationinfo-icon

    Source of Change: Measure Lead

Logic

  • Additional timing attributes were added to most datatypes in QDMinfo-icon 5.3 to facilitate accurate retrieval of time related information within CQL logic. Timing attributes now include a time interval, such as prevalence period or relevant period, and/or actual time of documentation with Author Datetime. Relevant period is the general method to describe start and stop times for datatypes. Prevalence period is used for some datatypes to more accurately define onset and abatement times.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Cardinality was assigned to each attribute to be more explicit in guiding specificationinfo-icon and implementation of QDM data elements. Cardinality refers to the number of instances of the attribute that can be included in the measure description. Cardinality for most attributes is 0.. 1 (i.e., can occur up to 1 time), but some attributes have a cardinality of 0.. * (i.e., can occur multiple times).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • CQL libraries contain sets of CQL definitions, or CQL expression statements. A context statement, patient or population, can now be used in a CQL library to clearly establish how the subsequent list of CQL expressions will be interpreted. A 'Population' context will interpret the CQL expression with reference to the entire population of the item being counted, patients or encounters. A 'Patient' context will interpret the CQL expression with reference to a single patient. Context statements are not required, but one or more context statements may be used within a library to help clarify how the CQL expressions will be interpreted. Patient context is the default if none is specified.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Replaced measure-defined definitions with similar definitions and functions from CQL shared libraries for consistency across measures.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated measure logic from Quality Data Model (QDM)-based logic to Clinical Quality Language (CQL)-based logic. Information on CQL can be found at the eCQI Resource centerinfo-icon (https://ecqi.healthit.gov/cql). Information about specific versions of the new standards in use for CMS reporting periods can be found at the eCQI Resource Center (https://ecqi.healthit.gov/ecqm-tools-key-resources). Switching from QDM to CQL brings with it many changes, as well as enhanced expression capability, but only those changes with significant impact will be outlined in technical release notes. For example, in the case of timing operators, changes may only be summarized if those changes impact the measure calculation.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Setinfo-icon

The VSACinfo-icon is the source of truth for the value set content, please visit the VSAC for downloads of current value setsinfo-icon.

  • Value set BP Screening Encounter Codes (2.16.840.1.113883.3.600.1920): Added 5 CPT codes (99236, 99315, 99316, 99339, 99340).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Anti-Hypertensive Pharmacologic Therapy (2.16.840.1.113883.3.600.1476): Deleted 2 RXNORM codes (247516, 901446).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Finding of Hypertension (2.16.840.1.113883.3.600.2395): Removed Finding of Hypertension.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 11 SOP codes (299, 32127, 32128, 391, 517, 524, 614, 621, 622, 623, 629) and deleted 3 SOP codes (63, 64, 69).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Replaced LOINC single code value sets with direct referenced codes. A direct referenced code is a single concept code that is used to describe a clinical element directly within the logic. The use of direct referenced codes replaces the need for single code value sets. Measures using other code systems in single value sets may optionally transition to direct referenced codes.

    Measure Section: QDM Data Elements

    Source of Change: Standards Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Deleted 1 SOP code (24).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Anti-Hypertensive Pharmacologic Therapy (2.16.840.1.113883.3.600.1476): Deleted 6 RXNORM codes (1009220, 1009247, 1009315, 1009320, 197497, 310139).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

External Resources