Description:  


The percentage of members 18–85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled during the measurement year based on the following criteria:

  • Members 18–59 years of age whose BP was <140/90 mm Hg.
  • Members 60–85 years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg.
  • Members 60–85 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg.


Note: Use the Hybrid Method for this measure. A single rate is reported and is the sum of all three groups

.

Definitions

Adequate control
Adequate control is defined as meeting any of the following criteria:
  • Members 18–59 years of age whose BP was <140/90 mm Hg.
  • Members 60–85 years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg.
  • Members 60–85 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg.
Representative BP
The most recent BP reading during the measurement year (as long as it occurred after the diagnosis of hypertension). If multiple BP measurements occur on the same date, or are noted in the chart on the same date, use the lowest systolic and lowest diastolic BP reading. If no BP is recorded during the measurement year, assume that the member is “not controlled.”



Denominator:    


Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Ages
18–85 years as of December 31 of the measurement year.
Continuous enrollment
The measurement year.
Allowable gap
No more than one gap in continuous enrollment of up to 45 days during the measurement year. To determine continuous enrollment for a Medicaid beneficiary for whom enrollment is verified monthly, the member may not have more than a 1-month gap in coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not considered continuously enrolled).


Anchor date
December 31 of the measurement year.
Benefit
Medical.
Event/diagnosis
Members are identified as hypertensive if there is at least one outpatient visit (Outpatient Without UBREV Value Set) with a diagnosis of hypertension (Essential Hypertension Value Set) during the first six months of the measurement year.

Diabetes Flag for Numerator Assessment

After the Eligible Population is identified, assign each member either a diabetic or not diabetic flag using only administrative data and the steps below. The flag is used to determine the appropriate BP threshold to use during numerator assessment (the threshold for members with diabetes is different than the threshold for members without diabetes).

Step 1

Assign a flag of diabetic to members identified as diabetic using claim/encounter data or pharmacy data. The organization must use both methods to assign the diabetes flag, but a member only needs to be identified by one method. Members may be identified as having diabetes during the measurement year or the year prior to the measurement year.
Claim/encounter data. Members who met any of the following criteria during the measurement year or the year prior to the measurement year (count services that occur over both years):
  • At least two outpatient visits (Outpatient Value Set), observation visits (Observation Value Set), ED visits (ED Value Set) or nonacute inpatient encounters (Nonacute Inpatient Value Set) on different dates of service, with a diagnosis of diabetes (Diabetes Value Set). Visit type need not be the same for the two visits.
  • At least one acute inpatient encounter (Acute Inpatient Value Set) with a diagnosis of diabetes (Diabetes Value Set).Pharmacy data. Members who were dispensed insulin or hypoglycemics/ antihyperglycemics on an ambulatory basis during the measurement year or the year prior to the measurement year (Table CDC-A).

Step 2

From the members identified in step 1, assign a flag of not diabetic to members who do not have a diagnosis of diabetes (Diabetes Value Set), in any setting, during the measurement year or year prior to the measurement year and who had a diagnosis of gestational diabetes or steroid-induced diabetes (Diabetes Exclusions Value Set), in any setting, during the measurement year or the year prior to the measurement year.
Note: Members classified as diabetic in step 1 based on pharmacy data alone and who had a diagnosis of gestational or steroid-induced diabetes as specified above are re-classified as not diabetic in this step.

Step 3

Assign a flag of not diabetic to members who were not assigned a flag in step 1 or step 2.


Hybrid Specification:


Denominator
A systematic sample drawn from the eligible population for each product line whose diagnosis of hypertension is confirmed by chart review. The organization may reduce the sample size using the prior year’s audited, product line-specific rate. Refer to the Guidelines for Calculations and Sampling for information on reducing the sample size.
To confirm the diagnosis of hypertension, the organization must find notation of one of the following in the medical record anytime during the member’s history on or before June 30 of the measurement year:
  • Hypertension.
  • HTN.
  • High BP (HBP).
  • Elevated BP (­BP).
  • Borderline HTN.
  • Intermittent HTN.
  • History of HTN.
  • Hypertensive vascular disease (HVD).
  • Hyperpiesia.
  • Hyperpiesis.
It does not matter if hypertension was treated or is currently being treated. The notation indicating a diagnosis of hypertension may be recorded in any of the following documents:
  • Problem list (this may include a diagnosis prior to June 30 of the measurement year or an undated diagnosis that is not part of the office visit note; see the Note at the end of this section).
  • Office note.Subjective, Objective, Assessment, Plan (SOAP) note.
  • Encounter form.
  • Diagnostic report.
  • Hospital discharge summary.
  • Statements such as “rule out HTN,” “possible HTN,” “white-coat HTN,” “questionable HTN” and “consistent with HTN” are not sufficient to confirm the diagnosis if such statements are the only notations of hypertension in the medical record.
  • If the diagnosis of hypertension cannot be confirmed, the member is excluded and replaced by the next member from the oversample.
Identifying
the medical record
Use one medical record for both the confirmation of the diagnosis of hypertension and the representative BP. All eligible BP measurements recorded in the record must be considered. If an organization cannot find the medical record, the member remains in the measure denominator and is considered noncompliant for the numerator.
Use the following steps to find the appropriate medical record to review.

Step 1

Identify the member’s PCP.

If the member had more than one PCP for the time period, identify the PCP who most recently provided care to the member.

If the member did not visit a PCP for the time period or does not have a PCP, identify the practitioner who most recently provided care to the member.

If a practitioner other than the member’s PCP manages the hypertension, the organization may use the medical record of that practitioner.

Step 2

Use one medical record to both confirm the diagnosis for the denominator and identify the representative BP level for the numerator. There are circumstances in which the organization may need to go to a second medical record to either confirm the diagnosis or obtain the BP reading, as in the following two examples.

If a member sees one PCP during the denominator confirmation period (on or before June 30 of the measurement year) and another PCP after June 30, the diagnosis of hypertension and the BP reading may be identified through two different medical records.

If a member has the same PCP for the entire measurement year, but it is clear from claims or medical record data that a specialist (e.g., cardiologist) manages the member’s hypertension after June 30, the organization may use the PCP’s chart to confirm the diagnosis and use the specialist’s chart to obtain the BP reading. For example, if all recent claims coded with 401 came from the specialist, the organization may use this chart for the most recent BP reading. If the member did not have any visit with the specialist prior to June 30 of the measurement year, the organization must go to another medical record to confirm the diagnosis.


Denominator Exclusions:  Note: Members in hospice are excluded from the eligible population. If a member is found to be in hospice or using hospice services during medical record review, the member is removed from the sample and replaced by a member from the oversample. Refer to General Guideline 20: Members in Hospice.

  • Exclude from the eligible population all members with evidence of end-stage renal disease (ESRD) (ESRD Value Set; ESRD Obsolete Value Set) or kidney transplant (Kidney Transplant Value Set) on or prior to December 31 of the measurement year. Documentation in the medical record must include a dated note indicating evidence of ESRD, kidney transplant or dialysis.
  • Exclude from the eligible population all members with a diagnosis of pregnancy (Pregnancy Value Set) during the measurement year.
  • Exclude from the eligible population all members who had a nonacute inpatient admission during the measurement year. To identify nonacute inpatient admissions:
  1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).
  2. Confirm the stay was for nonacute care based on the presence of a nonacute code (Nonacute Inpatient Stay Value Set) on the claim.
  3. Identify the admission date for the stay.


Numerator


Numerator
The number of members in the denominator whose most recent BP (both systolic and diastolic) is adequately controlled during the measurement year based on the following criteria:
  • Members 18–59 years of age as of December 31 of the measurement year whose BP was <140/90 mm Hg.
  • Members 60–85 years of age as of December 31 of the measurement year who were flagged with a diagnosis of diabetes and whose BP was <140/90 mm Hg.
  • Members 60–85 years of age as of December 31 of the measurement year who were flagged as not having a diagnosis of diabetes and whose BP was <150/90 mm Hg.To determine if the member’s BP is adequately controlled, the representative BP must be identified.
To determine if the member's BP is adequately controlled, the representative BP must be identified.
Administrative
None.
Medical record
Follow the steps below to determine representative BP.

Step 1

Identify the most recent BP reading noted during the measurement year. The reading must occur after the date when the diagnosis of hypertension was confirmed.
Do not include BP readings:
  • Taken during an acute inpatient stay or an ED visit.
  • Taken during an outpatient visit which was for the sole purpose of having a diagnostic test or surgical procedure performed (e.g., sigmoidoscopy, removal of a mole).Obtained the same day as a major diagnostic or surgical procedure (e.g., EKG/ ECG, stress test, administration of IV contrast for a radiology procedure, endoscopy).
  • Reported by or taken by the member.
If multiple readings were recorded for a single date, use the lowest systolic and lowest diastolic BP on that date as the representative BP. The systolic and diastolic results do not need to be from the same reading.

Step 2

Determine numerator compliance based on the following criteria:
  • Members 18–59 years of age as of December 31 of the measurement year whose BP was <140/90 mm Hg.
  • Members 60–85 years of age as of December 31 of the measurement year who were flagged with a diagnosis of diabetes and whose BP was <140/90 mm Hg.Members 60–85 years of age as of December 31 of the measurement year who were flagged as not having a diagnosis of diabetes and whose BP was <150/90 mm Hg.
The member is not compliant if the BP reading does not meet the specified threshold or is missing, if there is no BP reading during the measurement year or if the reading is incomplete (e.g., the systolic or diastolic level is missing).

Step 3

A single rate is reported for all three groups. Sum the numerator events from step 2 to obtain the rate.



Note

  • When confirming the diagnosis of hypertension, the intent is to identify the date when the provider became aware of the hypertension diagnosis and documented the diagnosis of hypertension in the medical record (versus the time the patient acquired hypertension).


  • Problem lists generally indicate established conditions; to discount undated entries might hinder confirmation of the denominator. If a problem list is found in an office visit note, it would be considered a dated problem list and the date of the visit must be used.


  • Organizations generally require an oversample of 10–15 percent to meet the MRSS for confirmed cases of hypertension.


  • Only administrative data should be used to assign the diabetes flag. The intent of the flag is to determine the appropriate BP threshold to use for the member during numerator assessment. The only exception is if the member is flagged as a diabetic but medical record evidence contains information that classifies the member as a valid data error. To meet criteria as a valid data error, the medical record must contain no evidence of diabetes and include a notation that refutes the diagnosis, as described in Substituting Medical Records in the Guidelines for Calculations and Sampling. In this case, the diabetes flag may be changed to “not diabetic,” but the member may not be removed from the sample