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  1. eCQM Issue Tracker
  2. CQM-7596

Qualifying home blood pressure readings for CMS #165, Quality ID #236

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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    • 202-360-0299
    • Peter Basch
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      Thank you for your inquiry for CMS165v13 (2025 Performance Period). It is correct that a qualifying encounter is required to meet denominator. There are currently no plans to exclude a qualifying encounter from the denominator criteria as this meets the measure's intent. Please note that 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/CMS165v13.html.
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      Thank you for your inquiry for CMS165v13 (2025 Performance Period). It is correct that a qualifying encounter is required to meet denominator. There are currently no plans to exclude a qualifying encounter from the denominator criteria as this meets the measure's intent. Please note that 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/CMS165v13.html .
    • CMS0165v13
    • Unless a series of steps are taken to qualify the documentation of a home blood pressure reading, appropriate care and control is not reflecting in the MET / UNMET status.

      Some progress has been made in the eCQM for Controlling High Blood Pressure over the past several years... most notably the inclusion of blood pressures from specified home devices (capable of digital reporting). That said, neither manual documentation or automated upload of such numbers count towards the measure, unless the readings are further meta-tagged as occurring during a qualifying encounter. And depending on the EHR, the number of steps and time to create a qualifying encounter is a barrier to having the measure accurately reflect good care.

      For example, in the EHR in use by our system, it takes several minutes to create a new encounter and add a qualifying SNOMED code. And while trained staff may follow such steps - busy clinicians are unlikely to add minutes to a workflow that is not intuitive.

            AIR EC eCQM Team AIR EC eCQM Team
            pbasch1 Peter Basch
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