download chevron-down chevron-right chevron-with-circle-down chevron-with-circle-up check circle-with-minus circle-with-plus export help-with-circle inbox link mail old-phone star-outlined star user v-card close close close Back to top
Top
Top of Content

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

Last updated: May 9, 2019

CMS Measure ID: CMS22v8
Version: 8
NQF Number: Not Applicable
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:
Measure Scoring: Proportion
Measure Type: Process
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 eCQMinfo-icon version number.

    Measure Section: eCQM Version number

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

Logic

  • Added reason for referral 'Finding of Elevated Blood Pressure or Hypertension' to the CQL definition 'Referral to Alternate Provider' to reflect intended functionality and correct a prior logic omission. This logic change includes the addition of a new value setinfo-icon Finding of Elevated Blood Pressure or Hypertension (2.16.840.1.113762.1.4.1047.514).

    Measure Section: Numeratorinfo-icon

    Source of Change: ONC Project Tracking System (JIRA)info-icon: CQMinfo-icon-3129

  • Added 'exists' to CQL definitions 'Follow Up One Year' and 'Hypertensive Interventions at Most Recent Blood Pressure Encounter' to clarify the logic and reflect intended functionality; to return a true/false value rather than a potential list of interventions.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Removed 'exists' and/or 'is not null' from definitions 'Has First Hypertensive Reading With Interventions,' 'Has Prehypertensive Reading With Interventions,' and 'Has Second Hypertensive Reading With Intervention' to clarify the logic and reflect intended functionality; removing the possibility of meeting the numerator criteria without fulfilling all of the intended conditions.

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (JIRA): CQM-3546

  • Updated the names of Clinical Quality Language (CQL)info-icon definitions, functions, and/or aliases for clarification and to align with CQL Style Guideinfo-icon.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7info-icon Standard: Clinical Quality Language Specificationinfo-icon, Release 1 STUinfo-icon 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MATinfo-icon) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Set

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

  • Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • ​Removed code systeminfo-icon versions from direct reference codes. Please refer to Appendix A of the Electronic Clinical Quality Measureinfo-icon Logic and Implementation Guidance document for a list of code system versions used in the eCQM specificationsinfo-icon for 2020 reporting/performance.

    Measure Section: Terminology

    Source of Change: Standards Update

  • Standardized purpose statement language in value sets across eCQMsinfo-icon. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Anti-Hypertensive Pharmacologic Therapy (2.16.840.1.113883.3.600.1476): Added 8 RxNorm codes (197956, 197958, 199797, 199798, 199799, 353386, 353387, 827073) and deleted 4 RxNorm codes (858593, 885880, 897719, 904561).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set BP Screening Encounter Codes (2.16.840.1.113883.3.600.1920): Deleted 2 SNOMED CT codes (30346009, 37894004). Added 7 CDT codes (D7111, D7220, D7230, D7240, D7241, D7250, D7251).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Diagnosis of hypertension (2.16.840.1.113883.3.600.263): Deleted 1 SNOMED CT code (185717000).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Dietary Recommendations (2.16.840.1.113883.3.600.1515): Added 7 SNOMED CT codes (289176001, 289177005, 437211000124103, 437231000124109, 437391000124102, 437421000124105, 438961000124108).

    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): Added Finding of Elevated Blood Pressure or Hypertension grouping value set, including SNOMED CT extensional value set (2.16.840.1.113762.1.4.1047.513), ICD-10-CM extensional value set (2.16.840.1.113762.1.4.1047.512), and SNOMED CT extensional value set (2.16.840.1.113883.3.600.2395). This grouping value set is used to define a reason for referral (attribute) in the Clinical Quality Language (CQL) logic.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (JIRA): CQM-3129

  • Value set Physical Activity Recommendation (2.16.840.1.113883.3.600.1518): Deleted ICD-9-CM extensional value set (2.16.840.1.113883.3.600.1517), including 1 ICD-9-CM code (V65.41).

    Measure Section: Terminology

    Source of Change: Annual Update

External Resources