CMS 165 - Controlling High Blood Pressure

Medical Codify

CMS165v5 (2017)

CMS165v6 (2018)

CMS165v7 (2019)

Description:  Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period.

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:  Equals 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.

Inverse Measure:  No

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, 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.


Initial Patient Population

Name Value Set
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: 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
Diagnosis: Essential Hypertension 2.16.840.1.113883.3.464.1003.104.12.1011


Equals Initial Population


Name Value Set
Physical Exam, Performed: Diastolic blood pressure LOINC version 2.63 Code 8462-4
Physical Exam, Performed: Systolic blood pressure LOINC version 2.63 Code 8480-6

Denominator Exclusion

Name Value Set
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: Essential Hypertension 2.16.840.1.113883.3.464.1003.104.12.1011
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
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
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
Procedure, Performed: Vascular Access for Dialysis 2.16.840.1.113883.3.464.1003.109.12.1011


Medical Codify

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