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 |
| Topped out: | No for Registry/QCDR and EHR, Yes for Claims |
| Telehealth Eligible: | No |
| Reporting methods: | Registry/QCDR, EHR, or Claims |
| Maximum points: | Registry/QCDR or EHR: 10 | Claims: 7 |
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.
Measure 317 FAQs
Q. Is this measure reportable via claims?
A. Yes.
Q. Are patient encounters conducted via telehealth allowable?
A. No, telehealth encounters are not allowable.
Q. Do I have to report this measure every time a patient has a blood pressure reading?
A. Yes, this measure should be reported at each visit.
Q. Will I still get credit if the patient has a normal blood pressure reading?
A. Yes.
Q. Do I need to provide a treatment plan if the patient has a normal blood pressure reading?
A. A treatment plan is not necessary if the patient has a normal blood pressure reading.
Q. What qualifies as a lifestyle modification?
Weight Reduction
Dietary Approaches to Stop Hypertension (DASH) Eating Plan
Dietary Sodium Restriction
Increased Physical Activity
Moderation in alcohol consumption
Q. What qualifies as a normal blood pressure reading?
A. Systolic BP <120 mmHg AND Diastolic BP < 80 mmHg
Q. We do not have an EHR but we do electronically bill our claims. Our practice has chosen to use 317 as one of the measures we would like to implement. How do I know if I can use this measure in my practice?
A. Check measure information at the QPP website; make sure the ‘collection type’ field says ‘Medicare Part B claims measures’.
Q. Do G-codes have to be included in the claim when billing Medicare?
A. Yes, the G-code needs to be included in the Step 6E section. The appropriate G codes can be found in the specifications under the ‘numerator options’ section. You should code for the applicable outcome of whether it was ‘performance met’, ‘denominator exception’ or ‘performance not met’.
Calculation
The numerator: The number of patients who were screened for high blood pressure and had a recommended follow-up plan documented if blood pressure is elevated or hypertensive.
The denominator: All patient visits for patients aged 18 years and older at the beginning of the measurement period.
Exclusions are removed from the denominator: Patient not eligible due to active diagnosis of hypertension.
Measure calculation example
Dr. Taylor saw 221 adult patients during the reporting period. Three patients are excluded from the denominator because they have an active diagnosis of hypertension. After the exclusion, the denominator is 218.
For 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 6.0 to 6.9 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. This is applicable only to small practices with 15 providers or fewer. A score of 99.99% earns 8.9 points, while a score of 100% earns 10 points when reporting via registry.
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 30% of the overall MIPS score.
Benchmarks for registry submissions
The table below shows CMS benchmarks for registry submissions.
Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
|---|---|---|---|---|---|---|---|---|---|---|
Performance rate |
0.12 - 14.22 |
14.23 - 28.15 |
28.16 - 41.52 |
41.53 - 66.92 |
66.93 - 89.39 |
89.40 - 97.17 |
97.18 - 99.81 |
99.82 - 99.99 |
-- |
100 |
Points |
1.0 - 1.9 |
2.0 - 2.9 |
3.0 - 3.9 |
4.0 - 4.9 |
5.0 - 5.9 |
6.0 - 6.9 |
7.0 - 7.9 |
8.0 - 8.9 |
-- |
10 |
Benchmarks for EHR submissions
The table below shows CMS benchmarks for EHR submissions.
Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
|---|---|---|---|---|---|---|---|---|---|---|
Performance rate |
0.05 - 4.33 |
4.34 - 14.37 |
14.38 - 18.88 |
18.89 - 22.50 |
22.51 - 25.38 |
25.39 - 28.46 |
28.47 - 31.88 |
31.89 - 36.16 |
36.17 - 44.95 |
>=44.96 |
Points |
1.0 - 1.9 |
2.0 - 2.9 |
3.0 - 3.9 |
4.0 - 4.9 |
5.0 - 5.9 |
6.0 - 6.9 |
7.0 - 7.9 |
8.0 - 8.9 |
9.0 - 9.9 |
10 |
Benchmarks for claims submissions
The table below shows CMS benchmarks for claims submissions.
Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | |
|---|---|---|---|---|---|---|---|
Performance rate |
0.37 - 29.60 |
29.61 - 80.91 |
80.92 - 96.29 |
96.30 - 99.40 |
99.41 - 99.85 |
99.86 - 99.99 |
100 |
Points |
1.0 - 1.9 |
2.0 - 2.9 |
3.0 - 3.9 |
4.0 - 4.9 |
5.0 - 5.9 |
6.0 - 6.9 |
7 |
