eCQM: Controlling High Blood Pressure (CMS 165v5)


Controlling High Blood Pressure


CMS 165v5

NQF Number:


NQS Domain:

Effective Clinical Care

Measure Type:

Intermediate Outcome

MIPS High Priority Measure:


Eligible for Quality Programs:

  • Merit-Based Incentive Payment System (MIPS)
  • Medicaid EHR Incentive Program (Meaningful Use)
  • Comprehensive Primary Care Plus (CPC+)


Percentage of patients 18-85 years of age who have a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period.

Reporting Requirements

  • Numerator: Patients whose blood pressure at the most recent visit is adequately controlled (<140/90 mmHg)) during the measurement period.

  • Denominator: Patients 18-85 years of age who have an active diagnosis of essential hypertension within the first six months of the measurement period or any time prior to the measurement period who also have an eligible visit (defined as chart notes with one of the following encounter types: Office Visit, Nursing Home Visit, Nurse Visit or Home Visit) during the measurement period.

    • Denominator Exclusions: Patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period. Also excludes patients with a diagnosis of pregnancy during the measurement period.

    • Denominator Exceptions: None

Performance Benchmark for MIPS: 80.90%
For further benchmarks and details on how this measure will be scored within the Quality performance category of MIPS, please click here.

Practice Fusion Suggested Workflow
Practice Fusion suggests the following workflow to help ensure that you are able to meet the requirements of this measure within the Practice Fusion EHR.

  1. Complete a blood pressure reading and record it in the EHR at every visit for patients who have an active diagnosis of hypertension, defined as the diagnosis codes listed below:

    1. ICD-10: I10

    2. ICD-9: 401.0, 401.1, 401.9

  2. In order for the diagnosis of hypertension to be recognized by the calculation, the diagnosis must include a valid start date that falls within the appropriate time frame specified in the denominator (Graphic 1).

  3. Patients whose blood pressure is uncontrolled should be monitored and a follow-up visit should be scheduled so that they can have their vital signs updated later in the measurement period.

Graphic 1. Measure Timeframes for Hypertension Diagnosis


Additional Measure Information

  • This 2016 measure version has been updated from the previous 2015 version specifications, incorporating the following change:

    • Guidance added indicating which blood pressure reading will be used where there are multiple readings taken on the same day.

  • To be recognized for the denominator exclusion, the patient must have at least one of the following diagnosis codes recorded in his or her chart:

    • Chronic Kidney Disease, Stage 5

      • ICD-10: N18.5

      • ICD-9: 585.5

    • End Stage Renal Disease

      • ICD-10: N18.6

      • ICD-9: 585.6

    • Pregnancy (see complete list of codes here)

  • In reference to the numerator, only blood pressure readings performed by a clinician in the provider’s office are acceptable for numerator compliance for this measure. Blood pressure readings from the patient’s home (including readings directly from monitoring devices) will not be counted.

  • If no blood pressure is recorded during the measurement period, the patient’s blood pressure is assumed “not controlled.”

  • Per the CMS measure specifications, the diagnosis of essential hypertension must be recorded in the patient chart prior to the numerator-eligible encounter, i.e. the most recent visit in the measurement period. If the diagnosis and the most recent encounter occur on the same date, a follow-up encounter during the measurement period, in which an updated controlled BP is recorded, will be necessary in order to meet the numerator requirements.

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