CMS 165 - Controlling High Blood Pressure

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Updated: 12/09/2021
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CMS 165 / Quality ID #236

Percentage of patients 18-85 years of age who had a diagnosis of hypertension overlapping the measurement period or the year prior to the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period.

Denominator:	Patients 18-85 years of age who had a visit and diagnosis of essential hypertension overlapping the measurement period or the year prior to the measurement period. Patient’s age is calculated based on the patient’s Date of Birth, which was entered when you created the patient’s account. Create a note detailing the patient’s office visit. The diagnosis of "Hypertension" is entered in the patient’s Problem List with a Start Date.
Denominator Exclusions:	Patients with evidence of end stage rental disease (ESRD), dialysis or renal transplant before or during the measurement period: "End Stage Renal Disease", "Pregnancy", or "Chronic Kidney Disease, Stage 5" is documented in the Problem List with a Start Date. These patients will be excluded from the denominator. If patient was in Hospice during the measurement period: Hospice is documented under Hospitalizations/Procedures in History. These patients will be excluded from the denominator. Exclude patients 66 and older who are living long term in an institution for more than 90 consecutive days during the measurement period: Long Term Care is documented under Hospitalizations/Procedures in History. These patients will be excluded from the denominator. Exclude patients 66 and older with advanced illness and frailty because it is unlikely that patients will benefit from the services being measured: Patient’s age is calculated based on the patient’s Date of Birth. "Advanced Illness" and "Frailty" is documented under Problems with a Start Date.
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. "Blood pressure (B/P)" is documented under Vitals with a date that is the same as date of service on the note.
Office Visit Documentation:	Enter Procedure Codes including E/M Codes or HCPCS Codes on the Superbill. Complete and sign the note. Once all steps have been completed, the measure will be added to the Quality Measures Report.
Guidance:	If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic readings as the most recent blood pressure reading.
Measure type:	Outcome
High Priority Measure:	Yes
Telehealth Eligible:	Yes