2023 # 317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

CMS Measure ID: #317

Collection Type: CQM

Reporting Frequency: All Visits

Outcome: No

High Priority: No

NQS Domain: Community, Population and Public Health

Measure Age: > 2 years

Instructions

This measure is to be submitted at each visit for patients seen during the measurement period. Merit-based Incentive Payment System (MIPS) eligible clinicians who submit the measure must perform the blood pressure screening at each patient visit by a MIPS eligible clinician and may not obtain measurements from external sources.

This measure may be submitted by MIPS eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. The intent of this measure is to screen patients for high blood pressure and provide recommended follow-up as indicated. Both the systolic and diastolic blood pressure measurements are required for inclusion. If there are multiple blood pressures on the same date of service, use the most recent (last reading documented) as the representative blood pressure. The documented follow-up plan must be related to the current BP reading as indicated, example: “Patient referred to primary care provider for BP management”.

Description

Percentage 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.

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: No
Capped at 7: No

Decile 0: 0 – 0.04
Decile 1: 0.05 – 12.03
Minimum: 12.04 – 21.48
Decile 3: 21.49 – 28.32
Decile 4: 28.33 – 35.86
Decile 5: 35.87 – 50.24
Decile 6: 50.25 – 71.52
Decile 7: 71.53 – 91.75
Decile 8: 91.76 – 98.68
Decile 9: 98.69 – 99.99
Decile 10: 100 – 100

eCQM

Topped out: No
Capped at 7: No

Decile 0: 0 – 0.05
Decile 1: 0.06 – 5.77
Minimum: 5.78 – 13.69
Decile 3: 13.7 – 17.67
Decile 4: 17.68 – 21.04
Decile 5: 21.05 – 23.95
Decile 6: 23.96 – 27.09
Decile 7: 27.1 – 30.58
Decile 8: 30.59 – 35.33
Decile 9: 35.34 – 44.33
Decile 10: 44.34 – 100

Denominator

DENOMINATOR:

All patient visits for patients aged 18 years and older at the beginning of the measurement period

Definition:

Not Eligible for High Blood Pressure Screening (Denominator Exclusion) –

Patient has an active diagnosis of hypertension prior to the current encounter

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years at the beginning of the measurement period

AND

Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 92002, 92004, 92012, 92014, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99236, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99424, 99491, D7111, D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7251, G0101, G0402, G0438, G0439

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, FQ, 93

AND NOT

DENOMINATOR EXCLUSION:

Patient not eligible due to active diagnosis of hypertension: G9744

Numerator

Patient 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

Definitions:

Blood Pressure (BP) Classification – BP is defined by four (4) BP reading classifications: Normal, Elevated, First Hypertensive, and Second Hypertensive Readings

Normal BP: Systolic BP (SBP) < 120 mmHg AND Diastolic BP (DBP) < 80 mmHg
Elevated BP: SBP of 120-129 mmHg AND DBP < 80 mmHg
First Hypertensive Reading: SBP of >= 130 mmHg OR DBP of >= 80 mmHg without a previous SBP of >= 130 mmHg OR DBP of >= 80 mmHg during the 12 months prior to the encounter
Second Hypertensive Reading: Requires a SBP >= 130 mmHg OR DBP >= 80 mmHg during the current encounter AND a most recent BP reading within the last 12 months SBP >= 130 mmHg OR DBP >= 80 mmHg

Recommended BP Follow-Up – The 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults from the American College of Cardiology and American Heart Association (2017 Guideline) recommends BP screening and thresholds as defined under Blood Pressure Classifications and recommends interventions based on the current BP reading as listed in the “Recommended Blood Pressure Follow- Up” Table below.

Recommended Nonpharmacologic Interventions (Lifestyle Modifications) – The 2017 Guideline outlines nonpharmacologic interventions which must include one or more of the following as indicated:

Weight Reduction
Dietary Approaches to Stop Hypertension (DASH) Eating Plan
Dietary Sodium Restriction
Increased Physical Activity
Moderation in alcohol (ETOH) Consumption

Recommended Blood Pressure Follow-Up Table BP Classification	Systolic BP mmHg	Diastolic BP mmHg	Recommended Follow-Up (must include all indicated actions for each BP Classification)
Normal BP Reading	< 120	AND < 80	No Follow-Up required
Elevated BP Reading	120-129	AND < 80	Rescreen BP in 2 to 6 months AND recommended nonpharmacologic interventions OR Referral to Alternate/Primary Care Provider
First Hypertensive BP Reading	>=130	OR >= 80	Rescreen BP > 1 day and < 4 weeks AND recommended nonpharmacologic interventions OR Referral to Alternate/Primary Care Provider
Second Hypertensive BP Reading	130-139 and NOT >=140	OR 80-89 and NOT >=90	Recommended nonpharmacologic intervention AND reassessment in 2 to 6 months AND an order for laboratory test or ECG for hypertension OR Referral to Alternate/Primary Care Provider
Second Hypertensive BP Reading	>=140	OR >=90	Recommended nonpharmacologic intervention AND BP-lowering medication AND reassessment within 4 weeks AND an order for laboratory test or ECG for hypertension OR Referral to Alternate/Primary Care Provider

Patients with a Documented Reason for not Screening or no Follow-Up Plan for High Blood Pressure (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).

NUMERATOR NOTE: Although the recommended screening interval for a normal BP reading is every year, to meet the intent of this measure, BP screening and follow-up must be performed at every patient visit. For patients with Normal blood pressure, a follow-up plan is not required (G8783). Denominator Exception(s) are determined on the date of the denominator eligible encounter.

Numerator Options:

Performance Met: Normal blood pressure reading documented, follow-up not required (G8783)

Performance Met: Elevated or Hypertensive blood pressure reading documented, AND the indicated follow-up is documented (G8950)

Denominator Exception: Documented reason for not screening or recommending a follow-up for high blood pressure (G9745)

Performance Not Met: Blood pressure reading not documented, reason not given (G8785)

Performance Not Met: Elevated or Hypertensive blood pressure reading documented, indicated follow-up not documented, reason not given (G8952)