Measure: CMS165
Controlling High Blood Pressure
Measure Versions
| eMeasure Code | Measure Year | Full Version Number | Title |
|---|---|---|---|
| CMS165v12 | 2024 | 12.0.000 | Controlling High Blood Pressure |
| CMS165v11 | 2023 | 11 | Controlling High Blood Pressure |
| CMS165v10 | 2022 | 10.0.000 | Controlling High Blood Pressure |
| CMS165v9 | 2021 | 9.2.000 | Controlling High Blood Pressure |
| CMS165v8 | 2020 | 8.5.000 | Controlling High Blood Pressure |
| CMS165v7 | 2019 | 7.3.000 | Controlling High Blood Pressure |
| CMS165v6 | 2018 | 6.2.000 | Controlling High Blood Pressure |
| CMS165v5 | 2017 | 5.0.000 | Controlling High Blood Pressure |
Description
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.Guidance
Patient Group Definitions
| Group | Description | Instructions Links |
|---|---|---|
| Initial Population | 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 | Webchart Instructions |
| Denominator | Equals Initial Population | Webchart Instructions |
| Denominator Exclusions | Patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period. Also exclude patients with a diagnosis of pregnancy during the measurement period. Exclude patients who are in hospice care for any part of the measurement period. 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. Exclude patients 66-80 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 advanced illness criteria: - Advanced illness with two outpatient encounters during the measurement period or the year prior - OR advanced illness with one inpatient encounter during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior Exclude patients 81 and older by the end of the measurement period with an indication of frailty for any part of the measurement period. Exclude patients receiving palliative care for any part of the measurement period. | Webchart Instructions |
| Numerator | Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period | Webchart Instructions |
| Numerator Exclusions | Not Applicable | Webchart Instructions |
| Denominator Exceptions | None |
Details
| Full eMeasure Code | eMeasure Identifier | Measure Year | Version | NQF # | GUID |
|---|---|---|---|---|---|
| CMS165v11 | 165 | 2023 | 11 | N/A | abdc37cc-bac6-4156-9b91-d1be2c8b7268 |
| Steward | Developer | Endorsed By |
|---|---|---|
| National Committee for Quality Assurance | National Committee for Quality Assurance | None |
| Scoring Method | Measure Type | Stratification | Risk Adjustment |
|---|---|---|---|
| Proportion | Intermediate Outcome | None | None |
Rate Aggregation
None
Improvement Notation
Higher score indicates better qualityRationale
Clinical Recommendation Statement
Definition
Transmission Format
Applicable Value Sets
| Category | Value Set | OID |
|---|---|---|
| Diagnosis | Chronic Kidney Disease, Stage 5 | 2.16.840.1.113883.3.526.3.1002 |
| Diagnosis | End Stage Renal Disease | 2.16.840.1.113883.3.526.3.353 |
| Diagnosis | Essential Hypertension | 2.16.840.1.113883.3.464.1003.104.12.1011 |
| Diagnosis | Frailty Diagnosis | 2.16.840.1.113883.3.464.1003.113.12.1074 |
| Diagnosis | Kidney Transplant Recipient | 2.16.840.1.113883.3.464.1003.109.12.1029 |
| Diagnosis | Pregnancy | 2.16.840.1.113883.3.526.3.378 |
| Encounter, Performed | Acute Inpatient | 2.16.840.1.113883.3.464.1003.101.12.1083 |
| Encounter, Performed | Annual Wellness Visit | 2.16.840.1.113883.3.526.3.1240 |
| Encounter, Performed | Emergency Department Visit | 2.16.840.1.113883.3.464.1003.101.12.1010 |
| Encounter, Performed | Encounter Inpatient | 2.16.840.1.113883.3.666.5.307 |
| Encounter, Performed | ESRD Monthly Outpatient Services | 2.16.840.1.113883.3.464.1003.109.12.1014 |
| Encounter, Performed | Frailty Encounter | 2.16.840.1.113883.3.464.1003.101.12.1088 |
| Encounter, Performed | Home Healthcare Services | 2.16.840.1.113883.3.464.1003.101.12.1016 |
| Encounter, Performed | Hospice Encounter | 2.16.840.1.113883.3.464.1003.1003 |
| Encounter, Performed | Nonacute Inpatient | 2.16.840.1.113883.3.464.1003.101.12.1084 |
| Encounter, Performed | Observation | 2.16.840.1.113883.3.464.1003.101.12.1086 |
| Encounter, Performed | Office Visit | 2.16.840.1.113883.3.464.1003.101.12.1001 |
| Encounter, Performed | Online Assessments | 2.16.840.1.113883.3.464.1003.101.12.1089 |
| Encounter, Performed | Outpatient | 2.16.840.1.113883.3.464.1003.101.12.1087 |
| Encounter, Performed | Palliative Care Encounter | 2.16.840.1.113883.3.464.1003.101.12.1090 |
| Encounter, Performed | Preventive Care Services - Established Office Visit, 18 and Up | 2.16.840.1.113883.3.464.1003.101.12.1025 |
| Encounter, Performed | Preventive Care Services-Initial Office Visit, 18 and Up | 2.16.840.1.113883.3.464.1003.101.12.1023 |
| Encounter, Performed | Telephone Visits | 2.16.840.1.113883.3.464.1003.101.12.1080 |
| Intervention, Order | Hospice Care Ambulatory | 2.16.840.1.113883.3.526.3.1584 |
| Intervention, Performed | Hospice Care Ambulatory | 2.16.840.1.113883.3.526.3.1584 |
| Intervention, Performed | Palliative Care Intervention | 2.16.840.1.113883.3.464.1003.198.12.1135 |
| Medication, Active | Dementia Medications | 2.16.840.1.113883.3.464.1003.196.12.1510 |
| Patient Characteristic Ethnicity | Ethnicity | 2.16.840.1.114222.4.11.837 |
| Patient Characteristic Payer | Payer | 2.16.840.1.114222.4.11.3591 |
| Patient Characteristic Race | Race | 2.16.840.1.114222.4.11.836 |
| Patient Characteristic Sex | ONC Administrative Sex | 2.16.840.1.113762.1.4.1 |
| Procedure, Performed | Dialysis Services | 2.16.840.1.113883.3.464.1003.109.12.1013 |
| Procedure, Performed | Kidney Transplant | 2.16.840.1.113883.3.464.1003.109.12.1012 |
| Symptom | Frailty Symptom | 2.16.840.1.113883.3.464.1003.113.12.1075 |