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  1. eCQM Issue Tracker
  2. CQM-4895

Remove blood pressure guidance that is not built into the technical specification



    • EP/EC eCQMs
    • Status: Open
    • Moderate
    • Resolution: Unresolved
    • None


      Brief Description of Measure:

      ​CMS165: Controlling High Blood Pressure:
      Percentage of patients 18-85 years of age who had a diagnosis of hypertension overlapping the measurement period or the year prior to the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period

      Description of Issue:

      We have received multiple questions from implementers regarding the guidance language below, in the second and third statements, that is not programmable:
      Do not include BP readings:
      -Taken during an acute inpatient stay or an ED visit
      -Taken on the same day as a diagnostic test or diagnostic or therapeutic procedure that requires a change in diet or change in medication on or one day before the day of the test or procedure, with the exception of fasting blood tests.
      -Taken by the patient using a non-digital device such as with a manual blood pressure cuff and a stethoscope.
      These statements have caused confusion as they do not correlate with the measure's technical specifications.

      Proposed Solution:

      We are removing the guidance language related to unprogrammable logic. 

      Guidance after change:

      Do not include BP readings:
      -Taken during an acute inpatient stay or an ED visit

      Rationale for Change:

      ​​Removing the two statements related to blood pressure readings from the guidance field that are not included in the technical specification will reduce confusion among implementers.




            khancock Mathematica EC eCQM Team
            sgearhart Mathematica EH eCQM Team
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