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Controlling High Blood Pressure

Updated: 10/24/2019
Views: 1132

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

Denominator: Patients 18 through 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.
  • Patient’s age is calculated based on the patient’s Date of Birth, which is entered when you created the patient’s account.
  • The diagnosis of Hypertension is entered in the patient’s Problem List.
  • Make sure to add a Start Date to the problem. The problem must have started in the first six months of the measurement period or any time prior to the measurement period.
Denominator Exclusions:
  • If Pregnancy, End Stage Renal Disease, or Chronic Kidney Disease, Stage 5 is documented in the Problem List, with a Start Date, these patients will be excluded from the numerator.
  • If Vascular Access for Dialysis, ESRD Monthly Outpatient Services, Dialysis Services or Kidney Transplant is documented in Procedures/Hospitalizations, these patients will be excluded from the denominator.
  • Exclude patients whose hospice care overlaps the measurement period.
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:

Once all steps have been completed, the measure will be added to the Quality 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.
Quality ID: 236
CMS Measure ID: CMS165
Measure type: Outcome
High Priority Measure: Yes
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