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Measure 317


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

Description: Percentage of adult patients who were screened for high blood pressure and received a follow-up plan where indicated.

Measure ID: 317

Type: Process

CMS Derm Specialty Set: Yes

High priority: No

Reporting methods: Registry/QCDR, EHR, or Claims

Maximum points: 10 

Measure purpose: This measure encourages physicians to assess patients for high blood pressure and to document a follow-up plan when necessary. High blood pressure is a major risk factor for disease and early death. 

Calculation

The numerator: The number of patients who were screened for high blood pressure and had a recommended follow-up plan documented if pre-hypertensive or hypertensive.

÷

The denominator: All adult patients with at least one eligible encounter during the reporting period.

Measure calculation example

Dr. Taylor saw 221 adult patients during the reporting period. This is the denominator.

Three patients are excluded from the denominator because they have an active diagnosis of hypertension.

In 207 of the remaining 218 patient encounters, Dr. Taylor screened the patient for high blood pressure and documented a follow-up plan when blood pressure was elevated. This is the numerator.

Quality of patient care = 207/218. Dr. Taylor has a score of 95% for this measure. This translates to 8.0 to 8.9 points when reporting by registry.

Important note

Because of how this measure is structured, physicians score 3 points even if they report on only one patient. Physicians receive no additional score for reporting scores that fall below 25.75%. For example, if Dr. Taylor reported on one patient encounter, she would earn 3 points.


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Quality measure score benchmark

CMS will award points based on a comparison of your performance rate to CMS benchmarks listed below. Reach the performance rate listed to achieve the corresponding points per measure. Points achieved for the Quality category will account for 45% of the overall MIPS score.

Benchmarks for registry submissions/QCDR submissions
Below 3 Decile 3Decile 4Decile 5Decile 6Decile 7Decile 8Decile 9Decile 10 
Performance rate  1 patient  25.75 - 
30.80
30.81 - 
35.46
34.47 - 
42.56
42.57 - 
59.14
59.15 - 
83.48
83.49 - 
97.31
97.32- 
99.99
100.00
Points  3 points  3 - 3.9  4 - 4.9 5 - 5.9 6 - 6.9 7 - 7.9 8 - 8.9 9 - 9.9 10
Benchmarks for claims submissions

The table below shows CMS benchmarks for claims submissions. 

Below 3 Decile 3Decile 4Decile 5Decile 6Decile 7Decile 8Decile 9Decile 10 
Performance rate  1 patient  34.25 - 
45.47
45.48
- 
58.48
58.49 - 
73.28
73.29 - 
89.40
89.41 - 
98.06
 98.07- 99.99 -- 100.00 
Points  3 points  3 - 3.9  4 - 4.9 5 - 5.9 6 - 6.9 7 - 7.9 8 - 8.9 9 - 9.9 10
Benchmarks for EHR submissions

The table below shows CMS benchmarks for EHR submissions. 

Below 3Decile 3Decile 4Decile 5Decile 6Decile 7Decile 8Decile 9Decile 10
Performance rate1 patient19.56 - 24.1324.14 - 28.1828.19 - 32.2032.31 - 36.6636.67 - 42.1142.12 - 50.6950.70 - 74.54>= 74.55
Points3 points3 - 3.94 -4.95 - 5.96 - 6.97 - 7.98 - 8.99 - 9.910

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