2020 MIPS Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Measure Description

Percentage of patients aged 18 years and older seen during the submitting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

Instructions

This measure is to be submitted a minimum of once per measurement period for patients seen during the measurement period. Merit-based Incentive Payment System (MIPS) eligible clinicians who submit the measure must perform the blood pressure screening at the time of a qualifying visit and may not obtain measurements from external sources.

This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. The intent of this measure is to screen patients for high blood pressure and provide recommended follow-up as indicated. Both the systolic and diastolic blood pressure measurements are required for inclusion. If there are multiple blood pressures on the same date of service, use the most recent (last reading documented) as the representative blood pressure. The documented follow-up plan must be related to the current BP reading as indicated, example: “Patient referred to primary care provider for BP management”.

Measure Submission Type:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

Denominator

All patients aged 18 years and older at the beginning of the measurement period with at least one eligible encounter during the measurement period

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years

AND

Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99281, 99282, 99283, 99284, 99285, 99215, 99236, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99339, 99340, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, D7111, D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7251, G0101, G0402, G0438, G0439

WITHOUT

Telehealth Modifier: GQ, GT, 95, POS 02

AND NOT

DENOMINATOR EXCLUSION:

Patient not eligible due to active diagnosis of hypertension: G9744

Numerator

Patients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated, if the blood pressure is pre-hypertensive or hypertensive

Definitions:

Blood Pressure (BP) Classification - BP is defined by four (4) BP reading classifications: Normal, Pre- Hypertensive, First Hypertensive, and Second Hypertensive Readings

Recommended BP Follow-Up - The Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends BP screening intervals, lifestyle modifications and interventions based on the current BP reading as listed in the “Recommended Blood Pressure Follow- Up Interventions” listed below

Recommended Lifestyle Modifications - The JNC 7 report outlines lifestyle modifications which must include one or more of the following as indicated:

• Weight Reduction
• Dietary Approaches to Stop Hypertension (DASH) Eating Plan
• Dietary Sodium Restriction
• Increased Physical Activity
• Moderation in alcohol (ETOH) Consumption

Second Hypertensive Reading - Requires a BP reading of Systolic BP ≥ 140 mmHg OR Diastolic BP ≥ 90 mmHg during the current encounter AND a most recent BP reading within the last 12 months Systolic BP ≥ 140 mmHg OR Diastolic BP ≥ 90 mmHg

Second Hypertensive BP Reading Interventions - The JNC 7 report outlines BP follow-up interventions for a second hypertensive BP reading and must include one or more of the following as indicated:

• Anti-Hypertensive Pharmacologic Therapy
• Laboratory Tests
• Electrocardiogram (ECG)

Recommended Blood Pressure Follow-up Interventions -

• Normal BP: No follow-up required for Systolic BP <120 mmHg AND Diastolic BP < 80 mmHg
• Pre-Hypertensive BP: Follow-up with rescreen every year with systolic BP of 120 – 139 mmHg OR diastolic BP of 80 – 89 mmHg AND recommended lifestyle modifications OR referral to Alternate/Primary Care Provider
• First Hypertensive BP Reading: Patients with one elevated reading of systolic BP >= 140 mmHg OR diastolic BP >= 90 mmHg:

• Follow-up with rescreen > 1 day and < 4 weeks AND recommend lifestyle modifications OR referral to Alternative/Primary Care Provider

• Second Hypertensive BP Reading: Patients with second elevated reading of systolic BP >= 140 mmHg OR diastolic BP >= 90 mmHg:

• Follow-up with Recommended lifestyle modifications AND one or more of the Second Hypertensive Reading Interventions OR referral to Alternative/Primary Care Provider

Recommended Blood Pressure Follow-Up Table

Not Eligible for High Blood Pressure Screening (Denominator Exclusion) -

• Patient has an active diagnosis of hypertension starts prior to the current encounter

Patients with a Documented Reason for not Screening or Follow-Up Plan for High Blood Pressure (Denominator Exception) –

NOTE: This denominator exception should be evaluated during the most recent encounter in the performance period with a documented blood pressure.

• Patient refuses to participate (either BP measurement or follow-up)
• Patient is in an urgent or emergent 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

NUMERATOR NOTE: Although the recommended screening interval for a normal BP reading is every 2 years, to meet the intent of this measure, BP screening and follow-up must be performed once per performance period. For patients with Normal blood pressure, a follow-up plan is not required (G8783). If the blood pressure is pre-hypertensive (SBP > 120 and <139 OR DBP >80 and <89) at a Primary Care Provider (PCP) encounter follow up as directed by the PCP would meet the intent of the measure (G8950).

Numerator Options:

Performance Met: Normal blood pressure reading documented, follow-up not required (G8783)

OR

Performance Met: Pre-Hypertensive or Hypertensive blood pressure reading documented, AND the indicated follow-up is documented (G8950)

OR

Denominator Exception: Documented reason for not screening or recommending a follow-up for high blood pressure (G9745)

OR

Performance Not Met: Blood pressure reading not documented, reason not given (G8785)

OR

Performance Not Met: Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not documented, reason not given (G8952)

Rationale

Hypertension is a prevalent condition that affects approximately 66.9 million people in the United States. It is estimated that about 20-40% of the adult population has hypertension; the majority of people over age 65 have a hypertension diagnosis (Appleton SL, et. al., 2012 and Luehr D, et. al., 2012). Winter (2013) noted that 1 in 3 American adults have hypertension and the lifetime risk of developing hypertension is 90% (Winter KH, et. al., 2013). The African American population or non-Hispanic Blacks, the elderly, diabetics and those with chronic kidney disease are at increased risk of stroke, myocardial infarction and renal disease. Non-Hispanic Blacks have the highest prevalence at 38.6% (Winter KH, et. al., 2013). Hypertension is a major risk factor for ischemic heart disease, left ventricular hypertrophy, renal failure, stroke and dementia (Luehr D, et. al., 2012).

Hypertension is the most common reason for adult office visits other than pregnancy. Garrison (2013) stated that in 2007, 42 million ambulatory visits were attributed to hypertension (Garrison GM and Oberhelman S, 2013). It also has the highest utilization of prescription drugs. Numerous resources and treatment options are available, yet only about 40- 50% of the hypertensive patients have their blood pressure under control (<140/90) (Appleton SL, et. al., 2012, Luehr D, et. al., 2012). In addition to medication non-compliance, poor outcomes are also attributed to poor adherence to lifestyle changes such as a low-sodium diet, weight loss, increased exercise and limiting alcohol intake. Many adults find it difficult to continue medications and lifestyle changes when they are asymptomatic. Symptoms of elevated blood pressure usually do not occur until secondary problems arise such as with vascular diseases (myocardial infarction, stroke, heart failure and renal insufficiency) (Luehr D, et. al., 2012).

Appropriate follow-up after blood pressure measurement is a pivotal component in preventing the progression of hypertension and the development of heart disease. Detection of marginally or fully elevated blood pressure by a specialty clinician warrants referral to a provider familiar with the management of hypertension and prehypertension. The 2010 ACCF/AHA Guideline for the Assessment of Cardiovascular Risk in Asymptomatic Adults continues to support using a global risk score such as the Framingham Risk Score, to assess risk of coronary heart disease (CHD) in all asymptomatic adults (Greenland P, et. al., 2010). Lifestyle modifications have demonstrated effectiveness in lowering blood pressure (JNC 7, 2003).

The synergistic effect of several lifestyle modifications results in greater benefits than a single modification alone. Baseline diagnostic/laboratory testing establishes if a co-existing underlying condition is the etiology of hypertension and evaluates if end organ damage from hypertension has already occurred. Landmark trials such as ALLHAT have repeatedly proven the efficacy of pharmacologic therapy to control blood pressure and reduce the complications of hypertension. Follow-up intervals based on blood pressure control have been established by the JNC 7 and the USPSTF.

Clinical Recommendation Statements

The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in adults age 18 years and older. This is a grade A recommendation.