CMS22v12 – Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

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

A qualifying visit in this case is an ‘Encounter to Screen for Blood Pressure’.

– 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.

Blood pressure readings are classified as follows:

1. Normal Blood Pressure: SBP < 120 mm Hg and DBP < 80 mm Hg
2. Elevated BP: SBP 120-129 mm Hg and DBP < 80 mm Hg
3. Hypertensive Stage 1: SBP 130-139 mm Hg and DBP 80-89 mm Hg
4. Hypertensive Stage 2: SBP ≥ 140 mm Hg and DBP ≥ 90 mm Hg

In case of an elevated reading, patients are prescribed non-pharmacological interventions.

In case of stage 1 hypertensive reading, patients are prescribed a follow up or referral and prescribed non-pharmacological interventions.

In case of stage 2 hypertensive reading, patients are prescribed a follow up within 4 months, non-pharmacological interventions, lab test/ECG for hypertension and medication (pharmacological intervention for hypertension).

Note: A non-pharmacological intervention includes; lifestyle recommendation, weight reduction recommendation, dietary recommendations, recommendation to increase physical activity, referral or counseling for alcohol consumption.

-DENOMINATOR EXCLUSION

Patients who have an active diagnosis of hypertension.

-DENOMINATOR EXCEPTION

• 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).

For Denominator:

To record an encounter, navigate to Patient > Provider Note > Create Superbill. Under the ‘Procedure–CPTs’ heading, enter the encounter code.

For Numerator:

• To record the systolic and diastolic blood pressure readings, navigate to Patient > Provider Note > Vitals. Click ‘Add’ and enter the blood pressure reading under the ‘Blood Pressure’ heading and click ‘Accept’.

Note: The blood pressure reading is to be taken during an ‘Encounter to Screen for Blood Pressure’.

• To document:
  • a non-pharmacological intervention
  • a referral or follow up
  • EKG study

use the workflow Patient > Provider Note > Evaluations. Click ‘Add’ and search for the relevant intervention. Select ‘Ordered’ from the ‘Status’ dropdown and click ‘Save & Accept’ or ‘Sign & Accept’.

• To order a laboratory test for hypertension, head over to Patient > Provider Note > Orders > Lab. Select a laboratory and search for a test, fill out any necessary details and once done, click ‘Save & Accept’ or ‘Sign & Accept’.

• To prescribe a pharmacological intervention for hypertension, navigate to Patient > Provider Note > Prescription. Here, click ‘Add’ and search for the medication. Fill out any details as needed and once done, click ‘Prescribe’.

For Denominator Exclusions:

The hypertension diagnosis can be documented via Patient > Provider Note > Diagnoses. Click ‘Add’ and search for the relevant diagnosis. Add the diagnosis details and click ‘Save’. Then click ‘Accept’ to add the diagnosis to the provider note.

For Denominator Exceptions:

Note: To document reasons for not recording vitals, users must set preferences from the Personal Module. Navigate to Personal > My Preferences > Patient. Mark the ‘Blood Pressure’ checkbox under the ‘Document Reasons for not recording’ heading. Then click ‘Save’.

• To document reasons for not screening for blood pressure, navigate to Patient > Clinical > Vitals. Click on the ‘Save’ button without recording the blood pressure reading. A pop up ‘Vitals not recorded’ appears. From the ‘Blood Pressure’ dropdown, select the relevant.

• To document medical reasons for not ordering a certain follow-up intervention, navigate to Patient > Provider Note > Evaluations. Click ‘Add’ and search for the relevant intervention. Select ‘Nor Ordered’ from the ‘Status’ dropdown and then select the relevant reason from the ‘Reason’ drop-down that appears. Once done, click ‘Save & Accept’ or ‘Sign & Accept’.

• The documentation of medical reasons for not prescribing medication can be done via Patient > Provider Note > Medications > Current > Discontinue. Here, the reason for discontinuing an active medication is to be selected from the drop-down.