Population Health
      Back to home
      1. Amazing Charts Knowledge Base
      2. How To Articles
      3. Population Health

      CMS22v13 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

      Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screen for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is elevated or hypertensive.

      Numerator

      Patient visits where patient were screened for high blood pressure AND have a recommended follow up plan documented, as indicated, if the blood pressure is elevated or hypertensive.

      Patients in the denominator will be included in the numerator if they have a documented BP reading in the Most Recent Encounter, and, if the BP is hypertensive or elevated, if they've recorded certain actions, interventions and plans.

      Blood Pressure is defined by four BP reading classifications:

      1. Normal BP: SBP < 120 mmHg AND DBP < 80 mmHg
      2. Elevated BP: SBP 120-129 mmHg AND DBP < 80 mmHg
      3. First Hypertensive Reading: SBP of >= 130 mmHg or DBP of >= 80 without a previous SBP of >= 130 mmHg OR DBP of >= 80 mmHg during the 12 months prior to the encounter
      4. Second Hypertensive Reading: SBP of >= 130 mmHg or DBP of >= 80 and a most recent BP reading within the last 12 months SBP of >= 130 mmHg OR DBP of >= 80 mmHg

       

      Please follow the following scenarios for the BP classification for your patient

      NORMAL BP

      Those patients with a normal BP will be added to the numerator without any additional action needed.

       

      Elevated BP Reading: 

      The blood pressure for the patient must be recorded in the Vitals section of the Most Recent Encounter.

      For those patients who this is the first time the BP has been found to be elevated, the clinician must either:

      Order a follow up within 6 months and recommend nonpharmacologic interventions (scenario 1)

      OR complete a referral (scenario 2).

       

      SCENARIO 1: Follow Up with re-screen within 6 months & recommend nonpharmacologic interventions

      The clinician must complete both of the following: ordering a follow up and recommend nonpharmacologic interventions. There are myriad of ways to document follow up and the interventions. AC has identified specific phrases for you to select in order for us to recognize completion, as outlined below.

      Follow Up within 6 Months

      Note: Choose one of the follow up options.

      • Text in the Encounter: The clinician, when writing in the patient's encounter, records in the Plan or Assessment any of the following phrases:
        • "blood pressure follow up plan"
        • "BP follow up plan"
        • "BP f/u plan"
        • "blood pressure follow up scheduled"
        • "BP follow up scheduled"
        • "BP f/u scheduled"
      • Order: Write an order in the Write Orders screen for a follow up visit, and include in the follow up order Comments section any of the following phrases:
        • blood pressure
        • BP
        • hypertension
        • HTN
      • Clinical Decision Support: The clinician will need to complete the following CDS rule:
        • High Blood Pressure in Adults: Screening rule
          • In the Results/Comments of that rule any of the following phrases:
            • Follow up
            • follow-up
            • followup
            • f/u

      Note: Patient must also have another visit within 6 months of the original visit and a BP reeding must be recorded at that follow up visit.

       

      Nonpharmacologic Interventions

      Note: Choose one of the following ways to document nonpharmacologic interventions.

      • Clinical Decision Support: Complete the following CDS rule:
        • Healthy Diet and Physical Activity: Counseling Adults with High Risk of CVD
      • Text in the Encounter: In the patient's encounter in the Plan or Assessment fields,  include any of the phrases below:
        • Dietary Recommendation
        • DASH
        • nutritional counseling
        • diet ed
        • dietary ed
        • weight reduction education
        • obesity follow up
        • obesity followup
        • obesity follow-up
        • obesity f/u
        • weight management
        • weight control
        • Lifestyle education
        • hypertension education
        • lifestyle recommendation
        • lifestyle modification recommendation
        • Alcohol Consumption
        • Alcohol counseling
        • Alcoholism counseling
        • alcohol rehab
        • alcoholism rehab
        • Referral to alcohol counseling
        • counseling about alcohol
        • Physical Activity
        • physical activity recommendation
        • recommendation to exercise
        • exercise education
        • strength training
        • exercise promotion
        • activity/exercise

      SCENARIO 2: Referral

      For Elevated Blood Pressure, the clinician must record a referral to an alternate physician or PCP. Any of the following will count as a referral:

      • Text in the Encounter: In the Most Recent Encounter Plan or Assessment field, or in the Comments/Results section of the "High Blood Pressure in Adults: Screening" Clinical Decision Support rule, use any of the following phrases:
        • referred for BP
        • referred for blood pressure
        • referred for HTN
        • referred for hypertension
      • Write an order for a referral: You can write an order for a referral in the Write Orders screen for a referral. In the Comments section for the referral, enter any of the following phrases to indicate the reason why you are referring a patient:
        • blood pressure
        • BP
        • hypertension
        • HTN
      • Save a Referral in the Demographics: Writes a referral for the patient and record it in the Demographics screen. In the Comments area, enter any of the following phrases to indicate the reason why you are referring a patient:
        • blood pressure
        • BP
        • hypertension
        • HTN

       

      FIRST HYPERTENSIVE SCREENING (SBP >= 130, DBP >= 80)

      The blood pressure for the patient must be recorded in the Vitals section of the Most Recent Encounter.

      For those patients who this is the first time the BP has been found to be hypertensive, the clinician must either:

      Order a follow up within 4 weeks and recommend nonpharmacologic interventions (scenario 1)

      OR complete a referral (scenario 2).

       

      SCENARIO 1: Follow Up & Lifestyle Modifications

      The clinician must complete both of the following: ordering a follow up and providing lifestyle modifications. There are myriad of ways to document follow up and the interventions. AC has identified specific phrases for you to select in order for us to recognize completion, as outlined below.

      Follow Up within 4 Weeks

      Note: Choose one of the follow up options.

      • Text in the Encounter: The clinician, when documenting in the patient's encounter, records in the Plan or Assessment any of the following phrases:
        • blood pressure follow up plan within 4 weeks
        • BP follow up plan within 4 weeks
        • BP f/u plan within 4 weeks
        • blood pressure follow up scheduled within 4 weeks
        • BP follow up scheduled within 4 weeks
        • BP f/u scheduled within 4 weeks
      • Order: Write an order in the Write Orders screen for a follow up visit, and include in the follow up order Comments section any of the following phrases:
        • blood pressure
        • BP
        • hypertension
        • HTN
      • Clinical Decision Support: The clinician, in addition to completing the Clinical Decision Support Rule "High Blood Pressure in Adults: Screening", and records in the Results/Comments of that rule any of the following phrases:
        • Follow up within 4 weeks
        • follow-up within 4 weeks
        • followup within 4 weeks
        • f/u within 4 weeks

      NOTE: Patient must also have another visit within 4 weeks of the original visit and a BP reeding must be recorded at that follow up visit.

       

      Nonpharmacologic Interventions

      Note: Choose one of the following ways to document nonpharmacologic interventions.

      • Clinical Decision Support: Complete the following CDS rule:
        • Healthy Diet and Physical Activity: Counseling Adults with High Risk of CVD
      • Text in the Encounter: In the patient's encounter in the Plan or Assessment fields,  include any of the phrases below:
        • Dietary Recommendation
        • DASH
        • nutritional counseling
        • diet ed
        • dietary ed
        • weight reduction education
        • obesity follow up
        • obesity followup
        • obesity follow-up
        • obesity f/u
        • weight management
        • weight control
        • Lifestyle education
        • hypertension education
        • lifestyle recommendation
        • lifestyle modification recommendation
        • Alcohol Consumption
        • Alcohol counseling
        • Alcoholism counseling
        • alcohol rehab
        • alcoholism rehab
        • Referral to alcohol counseling
        • counseling about alcohol
        • Physical Activity
        • physical activity recommendation
        • recommendation to exercise
        • exercise education
        • strength training
        • exercise promotion
        • activity/exercise

       

      SCENARIO 2: Referral

      For a First Hypertensive Blood Pressure, the clinician must record a referral to an alternate physician or PCP. Any of the following will count as a referral:

      • Text in the Encounter: In the Most Recent Encounter Plan or Assessment field, or in the Comments/Results section of the "High Blood Pressure in Adults: Screening" Clinical Decision Support rule, use any of the following phrases:
        • referred for BP
        • referred for blood pressure
        • referred for HTN
        • referred for hypertension
      • Write an order for a referral: You can write an order for a referral in the Write Orders screen for a referral. In the Comments section for the referral, enter any of the following phrases to indicate the reason why you are referring a patient:
        • blood pressure
        • BP
        • hypertension
        • HTN
      • Save a Referral in the Demographics: Writes a referral for the patient and record it in the Demographics screen. In the Comments area, enter any of the following phrases to indicate the reason why you are referring a patient:
        • blood pressure
        • BP
        • hypertension
        • HTN

       

      SECOND HYPERTENSIVE SCREENING (SBP of 130-139 mmHg OR DBP of 80-89 mmHg)

      At the second hypertensive screening, the provider must complete either

      Recommendation of nonpharmacologic intervention and reassessment within 6 months, as well as an order for a laboratory test or ECG for hypertension 

      OR a referral to an alternate provider (identical to Scenario 2 above)

       

      Recommendation of nonpharmacologic intervention

      Choose one nonpharmacologic intervention

      • Clinical Decision Support: Complete the following CDS rule:
        • Healthy Diet and Physical Activity: Counseling Adults with High Risk of CVD
      Text in the Encounter: In the patient's encounter in the Plan or Assessment fields, or in the CDS rule "High Blood Pressure in Adults: Screening" include any of the phrases below:
      • Weight Reduction
      • Heart Healthy Diet
      • Dietary Sodium Restriction
      • Increased Physical Activity
      • Moderation in alcohol
      • DASH

      Follow Up within 6 Months

      Note: Choose one of the follow up options:

      • Text in the Encounter: The clinician, when writing in the patient's encounter, records in the Plan or Assessment any of the following phrases:
        • blood pressure follow up plan
        • BP follow up plan
        • BP f/u plan
        • blood pressure follow up scheduled
        • BP follow up scheduled
        • BP f/u scheduled
      • Order: Write an order in the Write Orders screen for a follow up visit, and include in the follow up order Comments section any of the following phrases:
        • blood pressure
        • BP
        • hypertension
        • HTN
      • Clinical Decision Support: The clinician, in addition to completing the Clinical Decision Support Rule "High Blood Pressure in Adults: Screening", and records in the Results/Comments of that rule any of the following phrases:
        • Follow up
        • follow-up
        • followup
        • f/u

      Note: The patient must also have another visit within 6 months of the original visit and a BP reeding must be recorded at that follow up visit.

       

      INTERVENTION: Medication or Laboratory

      Note: Choose one of the intervention options.

      • Medication: Prescribe an anti-hypertensive pharmacologic therapy
      • Laboratory Tests: Tests, like the BMP, CMP, CBC, etc, should be saved in the Imported Items area manually, or should be received as an imported electronic result. Any of the following tests will count, as long as the test name  includes any of the phrases below:
        • BUN
        • BMP
        • BASIC METABOLIC PANEL
        • CMP
        • COMPREHENSIVE METABOLIC PANEL
        • CBC
        • Complete Blood Count
        • urinalysis
        • renal function
        • eGFR
        • albumin
        • creatinine
      • Electrocardiogram: electrocardiograms should be recorded in the plan or assessment, or written as an order.
        • Text in the Encounter: When documenting the encounter, the clinician should record any of the following phrases in the Plan or Assessment:
          • 12 lead EKG order
          • EKG order
          • ECG order
          • electrocardiogram order
        • As an Order: The name of the order would need to include any of the following phrases:
          • 12 lead EKG
          • EKG
          • ECG
          • electrocardiogram

      REFERRAL

      For the Second Hypertensive Blood Pressure reading, the clinician must record a referral to an alternate physician or PCP. Any of the following will count as a referral:

      • Text in the Encounter: In the Most Recent Encounter Plan or Assessment field, or in the Comments/Results section of the "High Blood Pressure in Adults: Screening" Clinical Decision Support rule, use any of the following phrases:
        • referred for BP
        • referred for blood pressure
        • referred for HTN
        • referred for hypertension
      • Write an order for a referral: You can write an order for a referral in the Write Orders screen for a referral. In the Comments section for the referral, enter any of the following phrases to indicate the reason why you are referring a patient:
        • blood pressure
        • BP
        • hypertension
        • HTN
      • Save a Referral in the Demographics: Writes a referral for the patient and record it in the Demographics screen. In the Comments area, enter any of the following phrases to indicate the reason why you are referring a patient:
        • blood pressure
        • BP
        • hypertension
        • HTN

      Denominator

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

      • Note: This measure count unique visits

      Denominator Exclusions

      Patient has an active diagnosis of hypertension

      Denominator Exceptions

      Any of the following reasons will count as an exception for the visit: 

      • Patient refuses to participate (either BP measurement or follow-up)
        • In the Plan or Assessment section of the Most Recent Encounter, enter the either of the following phrases:
          • Patient refuses BP Measurement
          • Patient refuses BP follow up
      • Medical Reason(s): 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. This may include but is not limited to severely elevated BP when immediate medical treatment is indicated:
        • In the Plan or Assessment section, enter any of the following phrases:
        • Urgent Situation. No BP measurement taken
        • Emergent Situation. No BP measurement taken
        • Medical contraindication indicated. No BP measurement taken