CMS22v6 – Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

All patients aged 18 years and older before the start of the measurement period with at least one eligible encounter during the measurement period. Eligible encounter is calculated through Visit codes and system captures these visits codes through eSuperbills or charges.

– DENOMINATOR EXCLUSION

Patient has an active diagnosis of hypertension before the encounter.

-DENOMINATOR EXCEPTION

Patient Reason(s):
Patient refuses to participate (either BP measurement or follow-up)

OR

Medical Reason(s):
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. This may include but is not limited to severely elevated BP when immediate medical treatment is indicated.

– NUMERATOR

Patients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated if the blood pressure is pre-hypertensive or hypertensive.

For Denominator:

A patient of age 18 years or older before start of the measurement period with at least one eligible encounter during the measurement period is included in the denominator.
To document encounter, naviagte to Patient > Provider Note > eSuperbill.
The documentation of  first encounter takes place when one visit code gets attached with the patient’s eSuperbill/ charge.

For Numerator:

To qualify for Numerator, navigate to Patient > Clinical > Vitals. Record a patient’s blood pressure. If you do not record it and click on Save, the system requires a reason for not entering the blood pressure.

If blood pressure of a patient exceeds 120/80, appropriate follow up must be planned. The follow up comprises of one or more of the following:

• Follow-Up with in a year of Intervention Performed
• BP Screening Encounter Codes
• Referral to Alternative Provider / Primary Care Provide:
• Medication for Anti-Hypertensive Pharmacologic Therapy:
• Laboratory Test, Order: Laboratory Tests for Hypertension
• Diagnostic Study, Order: ECG 12 lead or study order

1. Follow-Up with in a year of Intervention Performed: 

A follow up is required after patient has been screened for high blood pressure to record this, navigate to Patient > Clinical > Evaluations.

2.  BP Screening Encounter Codes:
The system captures these visits codes through eSuperbills or charges.
To record encounter, navigate to Patient > Provider Note > eSuperbill. The documentation of the first encounter takes place when one visit code gets attached with the patient’s eSuperbill/ charge.

3.  Referral to Alternative Provider / Primary Care Provider: 

In order to document a referral to alternate provider or primary care provider, navigate to Patient > Clinical > Evaluations. 

To know more about how to add Evaluations, click here.

2.  Medication for Anti-Hypertensive Pharmacologic Therapy: 

To document medications for Anti-hypertensive Pharmacologic therapy, navigate to Patient > Clinical > Medications. 

3.  Laboratory Tests for Hypertension:

In order to document a laboratory test, navigate to Patient > Clinical > Orders& Results > Lab 

4. Diagnostic Study ECG 12 lead:

To document diagnosis study, navigate to Patient > Clinical > Evaluation.

– DENOMINATOR EXCEPTION

If the follow up plan is refused by the patient, it must be documented so that the patient moves to denominator exception population of the measure. You can also document the reasons if a patient refuses to continue with the follow up plan.

To find out more about how to document patient refusals of clinical procedures, please visit: How to document Refusals or denials?

– DENOMINATOR EXCLUSION

Patient has an active diagnosis of hypertension before the encounter.