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CMS 165 - Controlling High Blood Pressure

Updated: 06/13/2023|Views: 2793

CMS 165 / Quality ID #236

Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of 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 by the end of the measurement period who had a visit and diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of 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 "Essential Hypertension" is entered in the patient’s Problems with a Start Date.
Denominator Exclusions: Patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period:
  • "End Stage Renal Disease" or "Chronic Kidney Disease, Stage 5" is documented under Problems with a Start Date. These patients will be excluded from the denominator.

Exclude patients with a diagnosis of pregnancy during the measurement period

  • "Pregnancy" is documented under Problems with a Start Date. These patients will be excluded from the denominator.

Exclude patients who are in hospice care for any part of the measurement period.

  • Hospice is documented under Hospice in History. These patients will be excluded from the denominator.

Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period.

  • Long Term Care is documented under Long Term Care Facility in History. These patients will be excluded from the denominator.
  • Patient’s age is calculated based on the patient’s Date of Birth.

Exclude patients 66 and older by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advance illness criteria:

  1. Advanced illness with two outpatient encounters during the measurement period or the year prior, OR
  2. Advanced illness with one inpatient encounter during the measurement period or the year prior, OR
  3. Taking dementia medications during the measurement period or the year prior
  • 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.

Exclude patients receiving palliative care for any part of the measurement period.

  • Palliative Care 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.

Measure type: Outcome
High Priority Measure: Yes
Telehealth Eligible: Yes
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