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CMS 165 - Controlling High Blood Pressure

Updated: 11/11/2020
Views: 1533

CMS 165 / Quality ID #236

Percentage of patients 18-85 years of age who had a diagnosis of hypertension overlapping 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.
  • 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.
  • Add a Start Date to the problem.
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:

Exclude patients 66 and older who are living long term in an institution for more than 90 days during the measurement period:

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:

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
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