CMS 22 - Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented

Overview

CMS22v8 (2020)
CMS22v9 (2021)
CMS22v10 (2022)

Identifiers

CMS eCQM ID	NQF eCQM ID	NQF	MIPS Quality ID
CMS22v10	–	–	317

*MIE only supports data collection and reporting using eCQM specifications

Definitions

Description	Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is elevated or hypertensive.
Initial Patient Population	All patient visits for patients aged 18 years and older at the beginning of the measurement period.
Denominator	Equals Initial Population.
Denominator Exclusions	Patient has an active diagnosis of hypertension.
Numerator	Patient visits where patients were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated, if the blood pressure is elevated or hypertensive.
Numerator Exclusions	–
Denominator Exceptions	Documentation of medical reason(s) for not screening for high blood pressure (e.g., patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient's health status). Documentation of patient reason(s) for not screening for blood pressure measurements or for not ordering an appropriate follow-up intervention if patient BP is elevated or hypertensive (e.g., patient refuses).

Additional Information

Measure Type	Process measure
Measure Scoring	Proportion measure
Granularity	Encounter
Improvement Notation	Higher score indicates better quality
Domain	Community/Population Health

Clinical Instructions

Track all 18+ year-old patients screened for high blood pressure, and ensure those with a pre-hypertensive or hypertensive blood pressure reading have a follow-up plan recommended and documented. Pre-hypertension is defined by blood pressure readings with a systolic pressure from 120 to 139 mm/Hg or a diastolic pressure from 80 to 89 mm/Hg. Hypertension is defined by readings greater than or equal to 140/90 mm/Hg.

Preferred Workflow

1. While documenting the Visit encounter, record the blood pressure, as appropriate
2. Open the Vitals section and enter the systolic and diastolic pressures
3. If the blood pressure is high and the patient is assessed prehypertensive or hypertensive, recommend a follow-up plan and document, accordingly
   1. Open the Preventive Care section
   2. Open the Hypertension Interventions picklist
   3. Order the appropriate follow-up items(s) for the patient OR
   4. E-prescribe an appropriate hypertension medication
4. Continue documenting the encounter, as needed
5. When completed, Close and Archive the encounter

Alternate Workflow

1. While documenting the Visit encounter, record the blood pressure, as appropriate
2. Open the Vitals section and enter the systolic and diastolic pressures
3. If the blood pressure is high and the patient is assessed prehypertensive or hypertensive, recommend a follow-up plan and document, accordingly
4. Complete and provide the follow-up plan, as appropriate
5. Continue documenting the encounter, as needed
6. When completed, Close and Archive the encounter

Evidence

Initial Patient Population

Name	Value Set
Encounter, Performed: Encounter to Screen for Blood Pressure	2.16.840.1.113883.3.600.1920

Denominator Exclusions

Name	Value Set
Diagnosis: Diagnosis of Hypertension	2.16.840.1.113883.3.600.263

Numerator

Name	Value Set
Diagnostic Study, Order: EKG 12 channel panel	LOINC Code 34534-8
Diagnostic Study, Order: EKG study	LOINC Code 11524-6
Intervention, Order: Dietary Recommendations	2.16.840.1.113883.3.600.1515
Intervention, Order: Follow Up Within 4 Weeks	2.16.840.1.113883.3.526.3.1578
Intervention, Order: Follow-up 2-3 months (finding)	SNOMEDCT Code 183624006
Intervention, Order: Follow-up 4-6 months (finding)	SNOMEDCT Code 183625007
Intervention, Order: Lifestyle Recommendation	2.16.840.1.113883.3.526.3.1581
Intervention, Order: Recommendation to Increase Physical Activity	2.16.840.1.113883.3.600.1518
Intervention, Order: Referral or Counseling for Alcohol Consumption	2.16.840.1.113883.3.526.3.1583
Intervention, Order: Referral to Primary Care or Alternate Provider	2.16.840.1.113883.3.526.3.1580
Intervention, Order: Weight Reduction Recommended	2.16.840.1.113883.3.600.1510
Laboratory Test, Order: Laboratory Tests for Hypertension	2.16.840.1.113883.3.600.1482
Medication, Order: Pharmacologic Therapy for Hypertension	2.16.840.1.113883.3.526.1577
Physical Exam, Performed: Diastolic blood pressure	LOINC Code 8462-4
Physical Exam, Performed: Systolic blood pressure	LOINC Code 8480-6

Source(s)

eCQI CMS22