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  1. eCQM Issue Tracker
  2. CQM-7211

CMS165v12 Controlling High Blood Pressure

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Icon: Moderate Moderate
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    • Debra M Barnhart
    • 4175767605
    • Mercy Health ACO, LLC
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      Thank you for your inquiry for CMS165v12 and CMS165v13. A qualifying encounter is required to meet denominator; however, the blood pressure reading evaluated in the numerator does not need to be associated with the qualifying encounter in the denominator or any other qualifying encounter.

      The measure looks for the most recent systolic/diastolic blood pressure reading NOT taken during an acute inpatient stay or an emergency department visit. Additional guidance on qualifying blood pressure readings can be found in the measure specification's "Guidance" section. Please review the measure specification for further details about measure requirements: https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS165v12.html. If you need assistance reading an eCQM, please refer to the resources available at eCQI Resource Center, such as "Guide for Reading eCQMs" or "Implementation Checklist eCQM Annual Update": https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=ecqm-resources&global_measure_group=eCQMs
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      Thank you for your inquiry for CMS165v12 and CMS165v13. A qualifying encounter is required to meet denominator; however, the blood pressure reading evaluated in the numerator does not need to be associated with the qualifying encounter in the denominator or any other qualifying encounter. The measure looks for the most recent systolic/diastolic blood pressure reading NOT taken during an acute inpatient stay or an emergency department visit. Additional guidance on qualifying blood pressure readings can be found in the measure specification's "Guidance" section. Please review the measure specification for further details about measure requirements: https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS165v12.html . If you need assistance reading an eCQM, please refer to the resources available at eCQI Resource Center, such as "Guide for Reading eCQMs" or "Implementation Checklist eCQM Annual Update": https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=ecqm-resources&global_measure_group=eCQMs
    • CMS0165v13
    • CMS0165v12
    • Capture of home blood pressure readings associated with encounters not included in the list of qualifying encounters.

      We have encountered problems related to the capture of home blood pressure readings for the CMS165v12 Controlling High Blood Pressure eCQM measure.  These home blood pressure readings may be reported in person, over the telephone, sent via the EHR’s patient portal, sent in via a SMS message or US mail.   These home blood pressure readings are documented in the manual (Home blood pressure readings) blood pressure flowsheet in the EHR but may be associated with an encounter type not recognized as a qualifying encounter (telephone call, patient outreach, etc).  Again, the CMS infrastructure (logic) does not provide for capture of these home blood pressure readings unless they are associated with a qualifying encounter.

            AIR EC eCQM Team AIR EC eCQM Team
            DebraBarnhart Debra Barnhart
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