CMS 165v13: Controlling High Blood Pressure

CPT: 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99395, 99396, 99397, 99385, 99386, 99387, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 98970, 98971, 98972, 99421, 99422, 99423, 99458, 98966, 98967, 98968, 99441, 99442, 99443, 98980, 98981, 99457

HCPCS: G0402, G0438, G0439, G0071, G2010, G2012, G2250, G2251, G2252

The patient must have an active diagnosis of essential hypertension at the start of the Measurement Period or be diagnosed with essential hypertension within the first six months of the Measurement Period. Diagnoses are documented in the Assessment tab of an encounter.

The eligible diagnosis codes for essential hypertension are:

ICD-10: I10

Diagnoses are documented in the Assessment tab of an encounter. A comprehensive list of eligible diagnosis codes for this exclusion can be located here.

To document the performance of a services received related to kidney disease or a kidney transplant, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below. Order Status must be marked as Complete in order to count as an exclusion.

Dialysis Services

CPT: 90947, 90945, 90940, 90937, 90935

HCPCS: G0257

Kidney Transplant

CPT: 50300, 50320, 50340, 50380, 50370, 50365, 50360

HCPCS: S2065

ESRD Monthly Outpatient Services

CPT: 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 90997, 90999, 99512

To document hospice care ambulatory services, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

CPT: 99377, 99378

HCPCS: G0182

Order Status must be marked as Pending or Complete.

To document hospice care encounter services, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

HCPCS: G9996, G9473, G9474, G9475, G9476, G9477, G9478, G9479, Q5003, Q5004, Q5005, Q5006, Q5007, Q5008, Q5010, S9126, T2042, T2043, T2044, T2045, T2046

Order Status must be marked as Complete.

Palliative care services can be documented using the FACIT-Pal Questionnaire flowsheet, as an order, or as a diagnosis.

FACIT-Pal Questionnaire Flowsheet

1. Go to Encounter > Flowsheets/Labs > Standard or Chart > Flowsheets/Labs > Standard

2. Click Add New Flowsheet

3. Select the FACIT-Pal Questionnaire flowsheet and click Add

4. Click Add Column

5. Populate the patient's responses to the questions as appropriate

6. Click OK to save

Palliative Care Services Order

Go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

HCPCS: G9054, M1017

Order Status must be marked as Complete.

Palliative Care Diagnosis

Diagnoses are documented in the Assessment tab of an encounter. The eligible diagnosis code for palliative care is:

ICD-10: Z51.5

To document a nursing home stay:

1. Go to Chart > Demographics > Patient Info

2. Click Update

3. Click Additional Info tab

4. Populate the Date field in the Pop. Info section

5. Select Patient lives in nursing home for Housing Status

6. Click Save

Blood pressure is documented in the Vitals tab of an encounter.

To document blood pressure, go to Encounter > Vitals > click Add/Column