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 IDNQF eCQM IDNQFMIPS Quality ID
CMS22v10โ€“โ€“317

*MIE only supports data collection and reporting using eCQM specifications

Definitions

DescriptionPercentage 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 PopulationAll patient visits for patients aged 18 years and older at the beginning of the measurement period.
DenominatorEquals Initial Population.
Denominator ExclusionsPatient has an active diagnosis of hypertension.
NumeratorPatient 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 Exclusionsโ€“
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 TypeProcess measure
Measure ScoringProportion measure
GranularityEncounter
Improvement NotationHigher score indicates better quality
DomainCommunity/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
  • Open the Preventive Care section
  • Open the Hypertension Interventions picklist
  • Order the appropriate follow-up items(s) for the patient

OR

  • E-prescribe an appropriate hypertension medication
  1. Continue documenting the encounter, as needed
  2. 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

NameValue Set
Encounter, Performed: Encounter to Screen for Blood Pressure2.16.840.1.113883.3.600.1920

Denominator Exclusions

NameValue Set
Diagnosis: Diagnosis of Hypertension2.16.840.1.113883.3.600.263

Numerator

NameValue Set
Diagnostic Study, Order: EKG 12 channel panelLOINC Code 34534-8
Diagnostic Study, Order: EKG studyLOINC Code 11524-6
Intervention, Order: Dietary Recommendations2.16.840.1.113883.3.600.1515
Intervention, Order: Follow Up Within 4 Weeks2.16.840.1.113883.3.526.3.1578
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 Recommendation2.16.840.1.113883.3.526.3.1581
Intervention, Order: Recommendation to Increase Physical Activity2.16.840.1.113883.3.600.1518
Intervention, Order: Referral or Counseling for Alcohol Consumption2.16.840.1.113883.3.526.3.1583
Intervention, Order: Referral to Primary Care or Alternate Provider2.16.840.1.113883.3.526.3.1580
Intervention, Order: Weight Reduction Recommended2.16.840.1.113883.3.600.1510
Laboratory Test, Order: Laboratory Tests for Hypertension2.16.840.1.113883.3.600.1482
Medication, Order: Pharmacologic Therapy for Hypertension2.16.840.1.113883.3.526.1577
Physical Exam, Performed: Diastolic blood pressureLOINC Code 8462-4
Physical Exam, Performed: Systolic blood pressureLOINC Code 8480-6

Source(s)

eCQI CMS22


Enterprise Health Documentation

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Last Build: Tue, 18 Jun 2024 18:57:47 EDT
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