CMS 165 - Controlling High Blood Pressure

Overview

CMS165v12 (2024)

CMS165v11 (2023)

CMS165v10 (2022)

Identifiers

CMS eCQM ID	NQF eCQM ID	NQF	MIPS Quality ID
CMS165v12	–	–	236

*MIE only supports data collection and reporting using eCQM specifications

Definitions

Description	Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period
Initial Patient Population	Patients 18-85 years of age by the end of the measurement period who had a visit during the measurement period and diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period
Denominator	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 are in hospice care for any part of the measurement period. Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period. Exclude patients 66 and older with an indication of frailty for any part of the measurement period who meet any of the following criteria: Advanced illness with two outpatient encounters during the measurement period or the year prior Advanced illness with one inpatient encounter during the measurement period or the year prior Taking dementia medications during the measurement period or the year prior Exclude patients 81 and older with an indication of frailty for any part of the measurement period. Exclude patients receiving palliative care during the measurement period.
Numerator	Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period
Numerator Exclusions	–
Denominator Exceptions	–

Additional Information

Measure Type	Intermediate Outcome measure
Measure Scoring	Proportion measure
Granularity	Patient
Improvement Notation	Higher score indicates better quality
Domain	Effective Clinical Care

Clinical Instructions

Using the Vitals section of the encounter, ensure blood pressure is recorded correctly and the systolic and diastolic observations are coded with the appropriate LOINC (i.e., 8480-6 and 8462-4). The patient also needs a diagnosis of hypertension under the Symptoms/Diagnosis section of the encounter, active within the first 6 months of the measurement period in order to populate the denominator.

Numerator Compliance

1. While documenting the encounter, ensure both the systolic and diastolic blood pressure is recorded accurately under the Vitals section of the encounter. For a patient to be compliant with the numerator, the most recent blood pressure values must be <140/90
2. The patient must have a diagnosis of hypertension under the Symptoms/Diagnosis or Smart Plan sections of the encounter.
3. Continue documenting the encounter as appropriate.
4. When complete, Close and Archive the encounter.

Denominator Exclusion Compliance

Workflow A

1. Use the Long-Term, Chronic, and End of Life Care instructions to document one or more of the following
   1. Palliative Care
   2. Hospice Care
   3. Frailty Device Use

Workflow B

1. While documenting the encounter, record an active Pregnancy diagnosis

• Use the Smart Plan section quick lists to record the condition

OR

• Use the Past Medical History section quick lists to record the condition

OR

• Use the Symptoms/Diagnosis section quick lists to record the condition

2. Continue documenting the encounter, as appropriate
3. When completed, Close and Archive the encounter

Evidence

Initial Patient Population

Name	Value Set
Diagnosis: Essential Hypertension	2.16.840.1.113883.3.464.1003.104.12.1011
Encounter, Performed: Annual Wellness Visit	2.16.840.1.113883.3.526.3.1240
Encounter, Performed: Home Healthcare Services	2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed: Office Visit	2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed: Online Assessments	2.16.840.1.113883.3.464.1003.101.12.1089
Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up	2.16.840.1.113883.3.464.1003.101.12.1025
Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up	2.16.840.1.113883.3.464.1003.101.12.1023
Encounter, Performed: Telephone Visits	2.16.840.1.113883.3.464.1003.101.12.1080

### Denominator Exclusions

Name	Value Set
Assessment, Performed: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)	LOINC Code 71007-9
Device, Applied: Frailty Device	2.16.840.1.113883.3.464.1003.118.12.1300
Device, Order: Frailty Device	2.16.840.1.113883.3.464.1003.118.12.1300
Diagnosis: Chronic Kidney Disease, Stage 5	2.16.840.1.113883.3.526.3.1002
Diagnosis: End Stage Renal Disease	2.16.840.1.113883.3.526.3.353
Diagnosis: Frailty Diagnosis	2.16.840.1.113883.3.464.1003.113.12.1074
Diagnosis: Kidney Transplant Recipient	2.16.840.1.113883.3.464.1003.109.12.1029
Diagnosis: Pregnancy	2.16.840.1.113883.3.526.3.378
Encounter, Performed: Acute Inpatient	2.16.840.1.113883.3.464.1003.101.12.1083
Encounter, Performed: Care Services in Long-Term Residential Facility	2.16.840.1.113883.3.464.1003.101.12.1014
Encounter, Performed: Emergency Department Visit	2.16.840.1.113883.3.464.1003.101.12.1010
Encounter, Performed: Encounter Inpatient	2.16.840.1.113883.3.666.5.307
Encounter, Performed: ESRD Monthly Outpatient Services	2.16.840.1.113883.3.464.1003.109.12.1014
Encounter, Performed: Frailty Encounter	2.16.840.1.113883.3.464.1003.101.12.1088
Encounter, Performed: Nonacute Inpatient	2.16.840.1.113883.3.464.1003.101.12.1084
Encounter, Performed: Nursing Facility Visit	2.16.840.1.113883.3.464.1003.101.12.1012
Encounter, Performed: Observation	2.16.840.1.113883.3.464.1003.101.12.1086
Encounter, Performed: Outpatient	2.16.840.1.113883.3.464.1003.101.12.1087
Encounter, Performed: Palliative Care Encounter	2.16.840.1.113883.3.464.1003.101.12.1090
Intervention, Order: Hospice care ambulatory	2.16.840.1.113762.1.4.1108.15
Intervention, Performed: Hospice care ambulatory	2.16.840.1.113762.1.4.1108.15)
Intervention, Performed: Palliative Care Intervention	2.16.840.1.113883.3.464.1003.198.12.1135
Medication, Active: Dementia Medications	2.16.840.1.113883.3.464.1003.196.12.1510
Procedure, Performed: Dialysis Services	2.16.840.1.113883.3.464.1003.109.12.1013
Procedure, Performed: Kidney Transplant	2.16.840.1.113883.3.464.1003.109.12.1012
Symptom: Frailty Symptom	2.16.840.1.113883.3.464.1003.113.12.1075

Numerator

Name	Value Set
Physical Exam, Performed: Diastolic blood pressure	LOINC Code 8462-4
Physical Exam, Performed: Systolic blood pressure	LOINC Code 8480-6

Source(s)

eCQI CMS165

Revision History

Date	Description
09/19/2024	Updated for the 2024 reporting period
04/22/2022	Updated for the 2022 reporting period
02/27/2020	Initial document creation