CMS65v6 – Hypertension: Improvement in Blood Pressure

All patients 18-85 years of age who meet the following criteria:

1. At least one encounter in the first six months of the measurement year
2. Active diagnosis of essential hypertension documented during that encounter
3. Uncontrolled baseline blood pressure at the time of that visit

– DENOMINATOR EXCLUSION

All patients with:

1. Evidence of end-stage renal disease (ESRD) on or prior to December 31 of the measurement year
2. Documentation of dialysis or kidney transplant
3. Diagnosis of pregnancy during the measurement year
4. Hospice care during the measurement year

– NUMERATOR

Patients whose follow-up blood pressure is:

At least 10 mmHg less than their baseline blood pressure (the blood pressure recorded at the earliest visit during the measurement period) or is adequately controlled. If a follow-up blood pressure reading is not recorded during the measurement year, the patient’s blood pressure is assumed “not improved”.

For Denominator:
The patient of age 18-85 with an active diagnosis of essential hypertension, a visit during the measurement period and uncontrolled blood pressure during that visit is included in the initial population for this measure.
To record blood pressure, navigate to Patient > Clinical > Vitals.

For Numerator:
On the second visit (which should be within six months of the first visit) during the measurement year of the same patient, if the blood pressure is at least 10 mmHg less than their baseline blood pressure or is adequately controlled, then that patient is included in the numerator. To document blood pressure, navigate to Patient > Provider Notes > Vitals. 

If the patient has:

• An evidence of end-stage renal disease(ESRD) diagnosis on or prior to December 31 of the measurement year
• Documentation of dialysis or kidney transplant
• Diagnosis of pregnancy during the measurement year

then the patient is excluded from the denominator.

You can set the threshold values of the Vitals (typical values being 200mmHg for systolic and 75mmHg for diastolic BP):

1. Click on the Settings icon from the top right corner of the Vitals tab.
2. This opens the Add Vitals Ranges popup.
3. Enter the values and click on the Save button.

DENOMINATOR EXCLUSION

All patients with:

1. Evidence of end-stage renal disease (ESRD) on or prior to December 31 of the measurement year
2. Documentation of dialysis or kidney transplant
3. Diagnosis of pregnancy during the measurement year
4. Hospice care during the measurement year