CMS 165 Controlling High Blood Pressure

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Overview

This measure reports the percentage of patients who had a diagnosis of hypertension and whose blood pressure was adequately controlled during the measurement period. For this measure, adequately controlled means the patient’s most recent encounter that qualified them for the numerator showed a diastolic blood pressure of < 90 mmHg and a systolic blood pressure of < 140 mmHg.

Only patients 18-85 years old are counted.

At a Glance

eMeasure ID	CMS165v8
NQF	0018
Used For?	Medicaid PI/Stage 3, MIPS (Quality), CPC +
Domain	Effective Clinical Care
MIPS Quality ID	236
MIPS Measure Type	Intermediate Clinical Outcome
MIPS High Priority?	Yes

Measure Specification and Value Sets

You should be familiar with this measure’s specification, Value Sets, and direct reference codes (if applicable). Refer to Downloading Measure Specifications and Value Sets for more information. Measure help now includes hyperlinks to the Value Sets used by this measure. You must be registered for a UMLS license and signed in to your account to see this content.

Identifying Event Times

See Identifying Event Times for important information about the logic this dashboard uses.

Amending Signed Notes

As a best practice, Notes should not be signed until they are finalized. Amending a signed Note (by making changes to it in Prime Suite and then re-saving it) will change a patient’s qualification for this measure. Re-signing the amended Note may allow the patient to qualify again, but only if it is re-signed during the time period required by the measure.

Documenting Recorded Medications in Prime Mobile

If using Prime Mobile to document a recorded medication, you must enter a non-zero duration. Entering a duration ensures the medication's end date calculates properly and that the medication can qualify for eCQMs. Otherwise, Prime Mobile defaults the medication's end date to midnight of the date recorded. Since this can cause the medication’s end date and time to occur before its start date and time, the medication would not count towards any eCQMs looking for active medications.

Measure Calculations

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	Initial Population
Numerator	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.

Measure Details

Initial Population/Denominator

Patients are counted in the denominator if each of the following are met:

1.

They were between 18-84 years old at the beginning of the measurement period. Patients who turned 85 years old on the second day of the measurement period will qualify. Patients who turned 86 years old during the measurement period will not qualify. Age is based on the date of birth (DOB) entered on the patient’s Information page.

2.

They had at least one non-voided face-to-face encounter during the measurement period. This must be documented in the Plan or E&M section of a Note using a code from one of the following Value Sets:

• Annual Wellness Visit
• Home Healthcare Services
• Office Visit
• Preventive Care Services-Initial Office Visit, 18 and Up
• Preventive Care Services – Established Office Visit, 18 and Up

3.

They had a diagnosis of essential hypertension. This diagnosis must be documented on the Problem List (with an Active status) using a code from the Essential Hypertension Value Set. This problem must have a start date and time that occurred within the first six months of the measurement period or at any time prior to the measurement period start date.

When documenting on the Problem List, a Date of Onset should be entered using the mm/dd/yyyyy format.

Denominator Exclusions

Patients are excluded from the denominator if they meet any of the following. Select a link for additional information.

• They were diagnosed with one of the following: pregnancy, chronic kidney disease (stage 5), or end-stage renal disease.
• They received monthly outpatient services related to end-stage renal disease.
• They had a kidney transplant.
• They had vascular access for dialysis.
• They were a kidney transplant recipient.
• They received dialysis services.
• They received hospice care.
• They spent more than 90 days cumulatively in long term care.
• They were 65-80 years old and had an advanced illness and frailty.
• They were 81 years old or older and had frailty.

When documenting an exclusion in Past Surgical History (PSHx) or the Problem List, a Date of Onset should be entered using the mm/dd/yyyyy format. For PSHx, use Code Mapper to ensure that the term you’re using has been mapped to a code from the correct Value Set (Chart > Vocab Admin > Code Mapper > PSHx).

Pregnancy, Chronic Kidney Disease (Stage 5), or End-Stage Renal Disease

Patients will be excluded from the denominator if they were diagnosed with one of the following: pregnancy, chronic kidney disease (stage 5), or end-stage renal disease.

This diagnosis must be indicated on the patient’s Problem List. It must be based on a code from one of the following Value Sets: Pregnancy, Chronic Kidney Disease, Stage 5 or End Stage Renal Disease. These can be indicated by a patient problem that overlapped the measurement period. This means that one of the following will be true: either its start date or end date occurred during the measurement period, both its start date and end date occurred during the measurement period, or its start date occurred before the beginning of the measurement period and its end date occurred after the end of the measurement period.

Monthly Outpatient Services Related to End-Stage Renal Disease

Patients will be excluded from the denominator if they received monthly outpatient services related to end-stage renal disease at any point in time prior to the measurement period end date. This must be documented in Orders Tracking History with a status of Returned or Reviewed using a code from the ESRD Monthly Outpatient Services Value Set.

Kidney Transplant

Patients will be excluded from the denominator if they had a kidney transplant at any point in time prior to the measurement period end date. This can be indicated by any of the following:

• An order, documented using a code from the Kidney Transplant Value Set. In Orders Tracking History, this order must have a status of Returned or Reviewed.
• A result value documented using codes from the Kidney Transplant Value Set. This must be documented with a vocabulary term in the Results or with a vocabulary term in a Flowsheet.
• Documentation in Past Surgical History (PSHx) using a code from the Kidney Transplant Value Set.

Vascular Access for Dialysis

Patients will be excluded from the denominator if they had vascular access for dialysis at any point in time prior to the measurement period end date. This can be indicated by any of the following:

• An order, documented using a code from the Vascular Access for Dialysis Value Set. In Orders Tracking History, this order must have a status of Returned or Reviewed.
• A result value documented using codes from the Vascular Access for Dialysis Value Set. This must be documented with a vocabulary term in the Results or with a vocabulary term in a Flowsheet.
• Documentation in Past Surgical History (PSHx) using a code from the Vascular Access for Dialysis Value Set.

Kidney Transplant Recipient

Patients will be excluded from the denominator if they were a kidney transplant recipient. This must be documented as a diagnosis in Past Medical History (PMHx), the Problem List, or in the Assessment section of Note, using a code from the Kidney Transplant Recipient Value Set. The diagnosis must have overlapped the measurement period. This means that one of the following will be true: either its start date or end date occurred during the measurement period, both its start date and end date occurred during the measurement period, or its start date occurred before the beginning of the measurement period and its end date occurred after the end of the measurement period. The following will qualify:

• An active diagnosis documented in Past Medical History (PMHx) on the Facesheet. The diagnosis must be documented with a valid onset date. Note that if the diagnosis is entered in Past Medical History (PMHx), the diagnosis will remain in the patient’s history indefinitely. The only way to end the diagnosis is to add it through the Problem List and enter a resolved date or inactivate it.
• An active, resolved, or inactive diagnosis on the Problem List. The diagnosis must be documented with a valid onset date. If resolved, the diagnosis must also have a valid resolved date.
• An active diagnosis in the Assessment section of Note.

When documenting on the Problem List, a Date of Onset should be entered using the mm/dd/yyyyy format.

Dialysis Services

Patients will be excluded from the denominator if they received dialysis services at any point in time prior to the measurement period end date. This can be indicated by either of the following:

• An order, documented using a code from the Dialysis Services Value Set. In Orders Tracking History, this order must have a status of Returned or Reviewed.
• A result value documented using a code from the Dialysis Services Value Set. This must be documented with a vocabulary term in the Results or a vocabulary term in a Flowsheet.

Hospice Care

Patients will be excluded from the denominator if they received hospice care. This must be documented with a vocabulary term in the Results or in a Flowsheet. This documentation must show one of the following:

• They were discharged from the hospital into hospice care during the measurement period. This must be documented with a vocabulary term using a parent code from the Encounter Inpatient Value Set and a child code using either of the following SNOMEDCT version 2019-05-10 direct reference codes:
  • 428371000124100, indicating a patient was Discharged to a health care facility for hospice care.
  • 428361000124107, indicating a patient was Discharged to home for hospice care.
• They received hospice care. This must be documented with a vocabulary term in a Flowsheet using a code from the Hospice care ambulatory Value Set. The date the provider enters this documentation must occur during the measurement period.
• They had an order for hospice care. This must be documented in the Plan or Results section of a Note using a code from the Hospice care ambulatory Value Set. This order must have been created during the measurement period.

Long Term Care

Patients who spent more than 90 days cumulatively in long term care during the measurement period will be excluded from the denominator. They must meet each of the following:

1.

They were 65 years old or older at the beginning of the measurement period, based on the date of birth (DOB) entered on the Information page.

2.

They spent more than 90 cumulative days in a long-term care facility during the measurement period, documented with an encounter. This encounter can be documented in a clinical note linked to a single day visit for each day the patient was in the long-term care facility or a clinical note linked to a multi-day visit. A single day visit must have a duration of 24 hours or greater to qualify. This means that the visit's end date must not occur less than 24 hours after the visit's start date. The encounter must be documented using codes from either of the following Value Sets:

• Care Services in a Long-Term Residential Facility
• Nursing Facility Visit

Patients 65-80 Years Old with Advanced Illness and Frailty

Patients 65-80 years old with advanced illness and frailty during the measurement period will be excluded from the denominator. This must be indicated by each of the following:

1.

They were 65 - 80 years old at the beginning of the measurement period, based on the date of birth (DOB) entered on the Information page.

2.

They had a device, diagnosis, or symptoms of frailty. This can be indicated by any of the following:

• An order for a device related to frailty created during the measurement period, documented in the Plan section of a Note, using codes from the Frailty Device Value Set.
• A device related to frailty was applied that overlapped the measurement period. This device must be documented in the Frailty widget, using codes from the Frailty Device Value Set.
• A diagnosis of frailty that overlapped the measurement period. This diagnosis must be documented using a code from the Frailty Diagnosis Value Set. This can be indicated by either of the following:
  • An active diagnosis documented in Past Medical History (PMHx) on the Facesheet. The diagnosis must be documented with a valid onset date. Note that if the diagnosis is entered in Past Medical History (PMHx), the diagnosis will remain in the patient’s history indefinitely. The only way to end the diagnosis is to add it through the Problem List and enter a resolved date or inactivate it.
  • An active, resolved, or inactive diagnosis on the Problem List. The diagnosis must be documented with a valid onset date. If resolved, the diagnosis must also have a valid resolved date.
• A frailty encounter that overlapped the measurement period, documented in the Plan or E&M section of a Note, using a code from the Frailty Encounter Value Set.
• A symptom of frailty that overlapped the measurement period, documented in the Frailty widget, using codes from the Frailty Symptom Value Set. They symptom must be documented with a valid onset date. If resolved, the symptom must also have a valid resolved date.

To overlap the measurement period, one of the following must be true: either its start date and time or end date and time occurred during the measurement period, both its start date and time and end date and time occurred during the measurement period, or its start date and time occurred before the beginning of the measurement period and its end date and time occurred after the end of the measurement period.

3.

They meet one of the following:

• They had two outpatient encounters for advanced illness. These encounters must meet each of the following:

a.

Each encounter must begin two years or less before the end of the measurement period.

b.

Each encounter must be documented in the Plan or E&M section of a Note, using a code from one of the following Value Sets: Outpatient Observation ED Nonacute Patient

c.

Each encounter must include a diagnosis of advanced illness documented using a code from the Advanced Illness Value Set. This must be documented in the Assessment section of the Note linked to the encounter.

• They had one inpatient encounter for advanced illness. This encounter must meet each of the following:

a.

The encounter began two years or less before the end of the measurement period.

b.

This encounter must be documented in the Plan or E&M section of a Note, using a code from the Acute Inpatient Value Set.

c.

The encounter must include a diagnosis of advanced illness documented using a code from the Advanced Illness Value Set. This must be documented in the Assessment section of the Note linked to the encounter.

• They had a prescription for a dementia medication that overlapped the measurement period or the year prior to the measurement period. This means that one of the following must be true: either its start date and time or end date and time occurred during the measurement period or the year prior to the measurement period, both its start date and time and end date and time occurred during the measurement period or the year prior to the measurement period, or its start date and time occurred before the beginning of the year prior to the measurement period and its end date and time occurred after the end of the measurement period. This can be documented in the Medication List as either a prescribed medication or recorded medication, using codes from the Dementia Medications Value Set.

Patients 81 Years Old and Older with Frailty

Patients 81 years old and older with frailty during the measurement period will be excluded from the denominator. This must be indicated by each of the following:

1.

They were 81 years old or older at the beginning of the measurement period, based on the date of birth (DOB) entered on the Information page.

2.

They had a device, diagnosis, or symptoms of frailty. This can be indicated by any of the following:

• An order for a device related to frailty created during the measurement period, documented in the Plan section of a Note, using codes from the Frailty Device Value Set.
• A device related to frailty was applied that overlapped the measurement period. This device must be documented in the Frailty widget, using codes from the Frailty Device Value Set.
• A diagnosis of frailty that overlapped the measurement period. This diagnosis must be documented using a code from the Frailty Diagnosis Value Set. This can be indicated by either of the following:
  • An active diagnosis documented in Past Medical History (PMHx) on the Facesheet. The diagnosis must be documented with a valid onset date. Note that if the diagnosis is entered in Past Medical History (PMHx), the diagnosis will remain in the patient’s history indefinitely. The only way to end the diagnosis is to add it through the Problem List and enter a resolved date or inactivate it.
  • An active, resolved, or inactive diagnosis on the Problem List. The diagnosis must be documented with a valid onset date. If resolved, the diagnosis must also have a valid resolved date.
• A frailty encounter that overlapped the measurement period, documented in the Plan or E&M section of a Note, using a code from the Frailty Encounter Value Set.
• A symptom of frailty that overlapped the measurement period, documented in the Frailty widget, using codes from the Frailty Symptom Value Set. They symptom must be documented with a valid onset date. If resolved, the symptom must also have a valid resolved date.

To overlap the measurement period, one of the following must be true: either its start date and time or end date and time occurred during the measurement period, both its start date and time and end date and time occurred during the measurement period, or its start date and time occurred before the beginning of the measurement period and its end date and time occurred after the end of the measurement period.

Numerator

Patients are counted in the numerator if their most recent blood pressure reading during the measurement period showed a result of Diastolic blood pressure < 90 mmHg and a Systolic blood pressure < 140 mmHg. These blood pressure readings must be documented in Vital Signs or with a vocabulary term in the Results or in a Flowsheet. The vocabulary term used when documenting these values must be mapped to the following version LOINC 2019-05-10 direct reference codes:

• 8480-6 indicating Systolic Blood Pressure
• 8462-4 indicating Diastolic Blood Pressure.

If the patient had multiple blood pressure readings on the day of their most recent blood pressure reading, the lowest systolic and lowest diastolic blood pressure reading of the day is used. For example, if a patient had a blood pressure reading of 139/100 and 142/89 on the day of their most recent blood pressure reading, 139/89 would be used.

Numerator Exclusions

Not applicable

Denominator Exception

Not applicable