CMS 165 - Controlling High Blood Pressure
Covered by this topic
Overview
CMS165v8 (2020)
CMS165v9 (2021)
CMS165v10 (2022)
Identifiers
| CMS eCQM ID | NQF eCQM ID | NQF | MIPS Quality ID |
| CMS165v10 | – | – | 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 who had a visit 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 |
|
| 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
New UI Visit Encounter (valid RC202109+)
Original Visit Encounter
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, within the first six months or more of the measurement period in order to populate the denominator.
- While documenting the encounter, ensure the blood pressure is recorded under the Vitals section of the encounter.
- Patient must have a diagnosis of hypertension under the Symptoms/Diagnosis section of the encounter.
- Continue documenting the encounter as appropriate.
- When complete, 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: ESRD Monthly Outpatient Services | 2.16.840.1.113883.3.464.1003.109.12.1014 |
| 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: 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)
WebChart Documentation
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Mon, 09 Sep 2024 13:50:46 UTC
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