Administrative bulletin: 2026-07-002 Quality information

Professional and facility Providers

Controlling High Blood Pressure (CBP)

KEY POINT: Helpful information and tips to address the CBP measure.

Measure importance:

• Known as the “silent killer,” high blood pressure, or hypertension, increases the risk of heart disease and stroke, two of the leading causes of death in the United States.
• A person with hypertension is four times more likely to die from a stroke and three times more likely to die from heart disease.
• The American Academy of Family Physicians (AAFP) strongly recommends clinicians treat adults who have hypertension to a standard blood pressure target (<140/90 mm Hg) to reduce the risk of all-cause and cardiovascular mortality.

Measure weighting: Triple weighted.

Measure description:

• Determined by the most recent BP reading during the current measurement year.
• If multiple readings are recorded for a single date, use the lowest systolic and lowest diastolic BP on that date. The systolic and diastolic results do not need to be from the same reading.
• A BP reading taken by a member with a digital device during a telehealth or telephone visit is acceptable and will count towards compliance. A BP reading taken by the member with a non-digital device will not meet criteria.
• Digital device: a battery-operated cuff that is placed on the member’s upper arm or wrist.
• A BP documented as an “average BP” (e.g., “average BP: 139/70”) is eligible for use.
• Acceptable BP readings: outpatient visit including telehealth, telephone, and e-visits.

Measure noncompliance:

• The member is not compliant if the BP is ≥140/90 mmHg, if there is no BP reading during the measurement year, or if the reading is incomplete (e.g., the systolic or diastolic level is missing).
• If an additional blood pressure value is received within the measurement year that is considered noncompliant, it may reopen a previously closed gap.
• Do not include BP readings that meet the following criteria:
• Emergency room (ER) visit.
• Acute-inpatient stay.
• Taken same day as a diagnostic or therapeutic procedure that requires a change in diet or medication on or one day before the BP reading, with exceptions of fasting blood tests.
• Blood pressure taken by the member using a non-digital device such as a manual blood pressure cuff and a stethoscope.
• Blood pressure ranges and thresholds do not meet the criteria for this measure. A distinct numeric result for both the systolic and diastolic BP reading is required for the numerator compliance.

Best practices:

• CPT II codes can be billed by any provider type.
• Refer eligible members to Capital’s Care Management program.
• Utilize Theon™ for open gap reports, to manage returned records and supplemental data submissions.
• Utilize Action Reports.
• Contact your Population Health Consultant for questions or concerns.

Exclusions:

• Members who died during the measurement year.
• Evidence of end-stage renal disease (ESRD), dialysis, nephrectomy or kidney transplant.
• Members 66 years of age and older living in long-term institution settings, with advanced illness, and/or frailty.
• In hospice or using hospice services anytime during the measurement year.
• Receiving palliative care during the measurement year.
• A diagnosis of pregnancy at any time during the measurement year.

Resources:

Controlling High Blood Pressure (CBP) - NCQA

HEDIS^® advanced illness and frailty guide

KEY POINT: Providers should exercise clinical judgment when determining allowable HEDIS^® exclusions, ensuring that each exclusion is medically appropriate, accurately documented, and aligned with HEDIS^® technical specifications to support high quality, patient centered care.

Appropriate billing and coding can substantially reduce medical record requests for HEDIS^® data collection purposes.

General rule: NCQA allows exclusions from certain HEDIS measures for patients with advanced illness and/or frailty, but the age limit depends on whether the patient has both conditions or frailty only.

• Both advanced illness and frailty 66-80 years old.
• Frailty only 81+ years old.

Exclusions: Exclusions require documentation and billing of both advanced illness and frailty (or frailty alone) in the medical record and on claims during the measurement year or the prior year.

Advanced illness: One or more of the following during the measurement year or the year prior:

• Filled a dementia medication prescription.
• Diagnosis of an advanced illness billed on two different dates of service.

Examples of advanced illness: Amyotrophic lateral sclerosis (ALS), dementia, heart failure, hepatic disease, multiple sclerosis, emphysema, end-stage renal disease (ESRD), leukemia, malignant neoplasm of the pancreas or brain, certain secondary malignant neoplasms, Parkinson’s disease, pulmonary fibrosis, and renal failure.

Frailty: Must have at least two indications of frailty billed on different dates of service during the measurement year. Both indicators of frailty can occur from July 1 of the year prior through December 31 of the measurement year.

Examples of frailty indicators:

• Frailty devices such as a cane, commode chair, hospital bed, supplemental oxygen, walker or wheelchair.
• Frailty diagnoses billed for bed confinement status, falls or history of falling, dependence on frailty devices listed above, dependence on care provider, muscle wasting, muscle weakness or pressure ulcers.
• Encounters billed for home health (skilled nursing, home health aide, or personal care services) or certain physician management and care coordination services for home health or hospice care.
• Frailty symptoms like difficulty walking, failure to thrive, gait abnormalities, underweight or abnormal weight loss, weakness, or other malaise.

Coding and documentation:

• ICD10, CPT^®, and HCPCS codes are used to identify patients for exclusion from HEDIS^® measures.
• Proper coding reduces medical record requests and ensures accurate reporting.
• Documentation of advanced illness and frailty must be maintained in the medical record and billed with the appropriate exclusion codes.
• Virtual care visits are acceptable for documenting exclusions.
• Palliative care exclusions can be applied based on any single claim with a palliative care code during the current year.

Resources:

Use the Guide to HEDIS^® Universal Exclusions Quality Measures Toolkit to view appropriate codes.

Professional Providers only

NEW annual wellness visit checklist available

KEY POINT: Capital is pleased to share a new Annual Wellness Visit (AWV) Checklist to help providers support accurate documentation and HEDIS reporting during Medicare AWVs.

The checklist serves as a one-page, quick reference to confirm that essential health-related activities—such as cancer screenings, social needs screenings, and appropriate blood tests—are discussed, completed, and documented during the visit.

Incorporate the AWV Checklist into your workflow to close care gaps, support quality performance, and ensure the care delivered is fully reflected in the medical record. Providers are encouraged to share this tool with their care teams and use it as part of routine Annual Wellness Visits.