When we’re reviewing your clinicians’ data, it may be helpful to know what we are looking for in order for us to verify to CMS that your data is accurate and complete. Measure 236 requires documentation of a diagnosis of hypertension and evidence that the diagnosis is adequately controlled (< 14/90 mmHg) during the performance period. If no blood pressure is recorded during the measurement period, the patient’s blood pressure is assumed “not controlled” and the “performance not met” numerator option should be chosen.
This documentation may be found in the patient’s medical record. The relevant document should be made available to the auditor for the patient requested.
What readings are eligible for inclusion in the numerator?
Only blood pressure readings performed in the physician office are eligible for inclusion in the numerator of this measure. Do not include blood pressure readings taken at the patient’s home (including readings directly from monitoring devices) or readings that are taken on the same day as a diagnostic test or diagnostic or therapeutic procedure that requires a change in diet or change in medication on or one day before the day of the test or procedure.