Measure 317 – Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Audit Criteria

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 317 requires documentation of a screening for high blood pressure on all patients aged 18 years and older during the performance period and documentation of a recommended follow-up plan if the patient is pre-hypertensive or hypertensive.

 

NOTE: Patients with an active diagnosis of hypertension that started prior to the performance period are excluded from this measure.

 

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 constitutes a follow-up plan?

The measure steward has provided a recommended blood pressure follow-up table which we have recreated below:

 

Recommended Blood Pressure Follow-Up Table

BP Classification

Systolic BP mmHg

Diastolic BP mmHg

Recommended Follow-Up (Must Include all Indicated Actions for Each BP Classification)

Normal BP Reading

< 120

AND < 80

No Follow-Up Required

Pre-Hypertensive BP Reading

≥ 120 and ≤ 139

OR ≥ 80 AND ≤ 89

Rescreen BP within a minimum of 1 year AND Recommend Lifestyle Modifications

OR

Referral to Alternative/Primary Care Provider

First Hypertensive BP Reading

≥ 140

OR ≥ 90

Rescreen BP within a minimum of > 1 day and < 4 weeks AND Recommend Lifestyle Modifications

OR

Referral to Alternative/Primary Care Provider

Second Hypertensive BP Reading

≥ 140

OR ≥ 90

Recommend Lifestyle Modifications AND 1 or more of the Second Hypertensive Reading Interventions

OR

Referral to Alternative/Primary Care Provider

 

Recommended Lifestyle Modifications (Must Include One of the Following):

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

 

Second Hypertensive BP Reading Interventions (Must Include One of the Following):

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