CMS 165 - Controlling High Blood Pressure

Overview

CMS165v8 (2020)
CMS165v9 (2021)
CMS165v10 (2022)

Identifiers

CMS eCQM IDNQF eCQM IDNQFMIPS Quality ID
CMS165v10236
*MIE only supports data collection and reporting using eCQM specifications

Definitions

DescriptionPercentage 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 PopulationPatients 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.
DenominatorEquals 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.

NumeratorPatients 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 TypeIntermediate Outcome measure
Measure ScoringProportion measure
GranularityPatient
Improvement NotationHigher score indicates better quality
DomainEffective 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.

  1. While documenting the encounter, ensure the blood pressure is recorded under the Vitals section of the encounter.
  2. Patient must have a diagnosis of hypertension under the Symptoms/Diagnosis section of the encounter.
  3. Continue documenting the encounter as appropriate.
  4. When complete, Close and Archive the encounter.

Evidence

Initial Patient Population

NameValue Set
Diagnosis: Essential Hypertension2.16.840.1.113883.3.464.1003.104.12.1011
Encounter, Performed: Annual Wellness Visit2.16.840.1.113883.3.526.3.1240
Encounter, Performed: ESRD Monthly Outpatient Services2.16.840.1.113883.3.464.1003.109.12.1014
Encounter, Performed: Home Healthcare Services2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed: Office Visit2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed: Online Assessments2.16.840.1.113883.3.464.1003.101.12.1089
Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up2.16.840.1.113883.3.464.1003.101.12.1025
Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up2.16.840.1.113883.3.464.1003.101.12.1023
Encounter, Performed: Telephone Visits2.16.840.1.113883.3.464.1003.101.12.1080

Denominator Exclusions

NameValue Set
Assessment, Performed: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)LOINC Code 71007-9
Device, Applied: Frailty Device2.16.840.1.113883.3.464.1003.118.12.1300
Device, Order: Frailty Device2.16.840.1.113883.3.464.1003.118.12.1300
Diagnosis: Chronic Kidney Disease, Stage 52.16.840.1.113883.3.526.3.1002
Diagnosis: End Stage Renal Disease2.16.840.1.113883.3.526.3.353
Diagnosis: Frailty Diagnosis2.16.840.1.113883.3.464.1003.113.12.1074
Diagnosis: Kidney Transplant Recipient2.16.840.1.113883.3.464.1003.109.12.1029
Diagnosis: Pregnancy2.16.840.1.113883.3.526.3.378
Encounter, Performed: Acute Inpatient2.16.840.1.113883.3.464.1003.101.12.1083
Encounter, Performed: Care Services in Long-Term Residential Facility2.16.840.1.113883.3.464.1003.101.12.1014
Encounter, Performed: Emergency Department Visit2.16.840.1.113883.3.464.1003.101.12.1010
Encounter, Performed: Encounter Inpatient2.16.840.1.113883.3.666.5.307
Encounter, Performed: Frailty Encounter2.16.840.1.113883.3.464.1003.101.12.1088
Encounter, Performed: Nonacute Inpatient2.16.840.1.113883.3.464.1003.101.12.1084
Encounter, Performed: Nursing Facility Visit2.16.840.1.113883.3.464.1003.101.12.1012
Encounter, Performed: Observation2.16.840.1.113883.3.464.1003.101.12.1086
Encounter, Performed: Outpatient2.16.840.1.113883.3.464.1003.101.12.1087
Encounter, Performed: Palliative Care Encounter2.16.840.1.113883.3.464.1003.101.12.1090
Intervention, Order: Hospice care ambulatory2.16.840.1.113762.1.4.1108.15
Intervention, Performed: Hospice care ambulatory2.16.840.1.113762.1.4.1108.15)
Intervention, Performed: Palliative Care Intervention2.16.840.1.113883.3.464.1003.198.12.1135
Medication, Active: Dementia Medications2.16.840.1.113883.3.464.1003.196.12.1510
Procedure, Performed: Dialysis Services2.16.840.1.113883.3.464.1003.109.12.1013
Procedure, Performed: Kidney Transplant2.16.840.1.113883.3.464.1003.109.12.1012
Symptom: Frailty Symptom2.16.840.1.113883.3.464.1003.113.12.1075

Numerator

NameValue Set
Physical Exam, Performed: Diastolic blood pressureLOINC Code 8462-4
Physical Exam, Performed: Systolic blood pressureLOINC Code 8480-6

Source(s)

eCQI CMS165


WebChart Documentation

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