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  2. CQM-6106

Clarification of CMS-165 exclusion criteria for blood pressures taken during "acute inpatient stay or an ED visit".

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      Thank you for your inquiry regarding CMS165v11 Controlling High Blood Pressure. The measure guidance states BP readings taken during an acute inpatient stay or an ED visit should not be included. Acute inpatient stays and ED visits are defined in the measure logic for Qualifying Diastolic Blood Pressure Reading and Qualifying Systolic Blood Pressure Reading using the "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307) and “Emergency Department Visit" (2.16.840.1.113883.3.464.1003.101.12.1010) value sets.

      You can review the codes contained within these value sets on the Value Set Authority Center (VSAC) at https://vsac.nlm.nih.gov/. In VSAC, click on the “Search Value Sets” tab, enter the value set ID and select the correct “Expansion Version” (i.e., eCQM Update 2022-05-05 for 2023 Performance Period.

      The intent is to exclude BP readings taken during acute inpatient and ED visit settings and not when patient is in observation. For example, you should use the SNOMED codes in the “Encounter Inpatient” value set to exclude BP readings; if SNOMED codes are not natively supported in your system, you may map clinically equivalent acute inpatient services, and if mapping is done, you should maintain documentation in case of a CMS audit.
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      Thank you for your inquiry regarding CMS165v11 Controlling High Blood Pressure. The measure guidance states BP readings taken during an acute inpatient stay or an ED visit should not be included. Acute inpatient stays and ED visits are defined in the measure logic for Qualifying Diastolic Blood Pressure Reading and Qualifying Systolic Blood Pressure Reading using the "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307) and “Emergency Department Visit" (2.16.840.1.113883.3.464.1003.101.12.1010) value sets. You can review the codes contained within these value sets on the Value Set Authority Center (VSAC) at https://vsac.nlm.nih.gov/ . In VSAC, click on the “Search Value Sets” tab, enter the value set ID and select the correct “Expansion Version” (i.e., eCQM Update 2022-05-05 for 2023 Performance Period. The intent is to exclude BP readings taken during acute inpatient and ED visit settings and not when patient is in observation. For example, you should use the SNOMED codes in the “Encounter Inpatient” value set to exclude BP readings; if SNOMED codes are not natively supported in your system, you may map clinically equivalent acute inpatient services, and if mapping is done, you should maintain documentation in case of a CMS audit.
    • CMS0165v11
    • Qualifying encounter clarification; what should or should not be including patients in metrics when they are in an inpatient unit but in an observation admission status.

      What is considered an "acute inpatient stay or an ED visit"?

      Specifically wondering if a patient is in an observation status during an ED visit or while bedded in an inpatient unit, should blood pressure measurements count toward this metric despite the provider dropping CPT codes that are consistently used in the ambulatory or clinic setting? 

      Needing clarification on if any blood pressure measurement taken in an inpatient unit or during an ED visit should be excluded despite the patient's admission status or dropping of a qualifying CPT visit code.

            edave Mathematica EC eCQM Team
            lynne.nelson Lynne Nelson
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