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Value Based CareOctober 22, 2026

How to Close Blood Pressure Control Gaps Between Visits

Matteo

Updated October 2026. Written by Matteo Grassi, clinical psychologist and cofounder of HANA Health.

Controlling High Blood Pressure is a quality measure that counts the share of adults ages 18 to 85 with hypertension whose most recent blood pressure reading of the year is below 140/90 mm Hg. In the 2027 Medicare Star Ratings it carries a weight of 3, so one good reading late in the year matters a great deal.

As a clinical psychologist, I'd add that a blood pressure number is as much a scheduling and trust problem as a medication problem.

Key facts

What is the Controlling High Blood Pressure measure?

It's a yes or no test applied to each patient with hypertension: was the last reading of the year under 140/90? The CMS specification for the MIPS version describes patients ages 18 to 85 with essential hypertension, and the health plan version in HEDIS uses the same 140/90 threshold.

Both numbers have to pass. A reading of 138/92 fails, and so does 142/84. If a patient has several readings on the same day, the lowest systolic and the lowest diastolic from that day are used, even if they came from different readings.

The score is a percentage of patients, not a count of visits. That's why a practice can run a busy clinic all year and still miss, because a patient whose only reading was taken in February and was high stays in the "not controlled" column.

Where it matters: the measure feeds the Star Ratings that Medicare Advantage plans are paid on, and it sits on the list of ACO quality measures practices influence most. It's also a high priority intermediate outcome measure in MIPS.

Which blood pressure readings count?

Readings taken by a clinician or by a digital device count. Readings that come from a manual cuff and stethoscope used by the patient don't. The CMS specification also says readings from remote electronic monitors and from automated devices that the patient reports to the practice are acceptable.

Here's the checklist of what is excluded as a reading:

  • Hospital and ED readings: any reading taken during an acute inpatient stay or an emergency department visit.
  • Procedure day readings: a reading taken the same day as a test or procedure that required a change in diet or medication on or one day before, except fasting blood tests.
  • Non digital patient readings: a reading the patient took with a non digital device.
  • Ranges and thresholds: a note such as "under 140" doesn't count, because the measure needs one numeric systolic and one numeric diastolic value.

Common low intensity visits, such as a vaccination or a B-12 injection, don't disqualify a reading from that day. Documentation matters as much as the number: record the exact values and the date, and say when a patient reported the reading from a home device.

Health plans also ask practices to bill CPT II codes on the claim, such as 3074F for a systolic reading below 130, 3075F for 130 to 139, and 3077F for 140 or higher, per the Alliance Health Plan HEDIS MY2026 practitioner guide.

Why does the last reading of the year matter so much?

Because the measure only looks at the most recent reading in the year. Earlier readings, including good ones, don't rescue a high reading at the end of the year.

Think about two patients. One had 128/78 in March and 146/90 in November. The other had 152/94 in March and 132/80 in November. The second patient closes the gap. The first doesn't.

That timing creates two practical consequences. First, the final quarter is when practices have the most leverage, since a visit or a home reading in October, November or December can replace an older high number. Second, a patient who disappears for a year is counted as not controlled, so reach matters as much as clinical skill.

CMS weights this measure at 3, the same as the blood sugar measure and the readmissions measure, and well above the process measures that count 1, per the CMS measures and weights table. The Star Ratings fact sheet shows the 2027 results were published on October 8, 2026.

What closes blood pressure gaps between visits?

The strongest evidence points to home monitoring combined with human follow up and medication adjustment, not to home monitoring alone.

Here's what the research shows:

  • Home monitoring alone: a 2013 meta-analysis of 52 studies found lower pressure at 6 months, with systolic down 3.9 mm Hg, but not at 12 months, per Uhlig et al., Annals of Internal Medicine, 2013.
  • Home monitoring plus support: the same review found systolic reductions of 3.4 to 8.9 mm Hg at 12 months in good quality studies.
  • Team based care: nonphysician medication titration reduced systolic pressure by 7.1 mm Hg, per Mills et al. in 2017.
  • Telemonitoring with pharmacists: the 2017 ACC and AHA guideline review described one trial where telemonitoring with pharmacist management lowered systolic pressure by 12.4 mm Hg compared with usual care, per Reboussin et al., JACC, 2017.

The 2024 Hypertension Research meta-analysis added that upper arm cuffs worked and wrist cuffs didn't, and that results were stronger with telemonitoring or extra medical support.

Honest limits matter here. Most of these trials followed patients for a year or less, and the Annals review found the evidence on heart attacks, strokes and other clinical outcomes was insufficient. The reductions are modest on average. A 3 mm Hg change moves a patient at 142 to 139, which closes a gap for some people and does nothing for those at 160.

How does a practice set up a between visit workflow?

Start with the patients who are closest to the line, because they're the cheapest gaps to close. Here's a workable sequence:

  1. Pull the list of patients with hypertension and sort by most recent reading. Flag everyone with a last reading of 140/90 or higher, and everyone with no reading this year.
  2. Confirm each patient has a validated upper arm home cuff, and teach proper measuring technique at the first visit.
  3. Ask for readings on a set schedule, and have a clinician review them so someone acts on the numbers.
  4. Route high readings to a clinician who can adjust medication, since the evidence is strongest when titration is part of the loop.
  5. Bring patients who can't be controlled remotely in for a visit, and take a repeat reading if the first one is high.
  6. Document the exact numbers, the date, and the device, and bill the CPT II codes on the claim.
  7. Recheck the list in the fourth quarter and close the remaining gaps.

None of this works if patients don't pick up the phone or don't send readings. That's the part that breaks most programs.

What this means for your practice

Treat the last reading of the year as the target, and treat October as the month to work the list. Know which of your patients have a most recent reading above the line or no reading at all, and decide who will contact them.

Be careful with expectations. Remote monitoring only helps if someone reviews the readings and a clinician can change treatment, so build the clinical response before you build the outreach.

HANA builds phone based outreach that helps patients enroll, remember to take readings and book the follow up visit. It supports your clinical team and doesn't replace clinical judgment. You can read more on the HANA Remote page.

Frequently asked questions

Does a blood pressure my patient takes at home count?

It can. The CMS specification accepts readings from automated digital devices that patients report to the practice, as long as the exact values are documented. Readings taken with a non digital device by the patient don't count.

What happens if a patient has no blood pressure reading all year?

CMS treats a patient with no recorded blood pressure during the measurement period as not controlled. That's why missing patients hurt the score as much as high readings do.

Can a telehealth visit count toward this measure?

The CMS specification says the measure applies to the telehealth setting, so a qualifying telehealth encounter can place a patient in the denominator. A reading still has to come from a clinician or a digital device and carry exact numeric values.

Which patients are excluded from the measure?

Examples in the HEDIS guide include patients in hospice or palliative care, patients with pregnancy in the measurement year, and patients with end stage renal disease, dialysis or a kidney transplant. Check the current specification for your plan or program.

How many readings should we record at one visit?

Record every reading, and expect the plan to use the lowest systolic and lowest diastolic from the most recent date. A repeat reading after a high first reading is good practice.

Sources

  1. Centers for Medicare and Medicaid Services, 2027 Star Ratings Measures and Weights, 2026.
  2. Centers for Medicare and Medicaid Services, 2027 Medicare Advantage and Part D Star Ratings fact sheet, October 8, 2026.
  3. CMS Quality Payment Program, Quality ID 236: Controlling High Blood Pressure, 2026 MIPS CQM specification, 2026.
  4. Alliance Health Plan, Practitioner Clinical Guide, HEDIS MY2026 Adult Measures, 2026.
  5. Uhlig K et al., Self-Measured Blood Pressure Monitoring in the Management of Hypertension, Annals of Internal Medicine, 2013.
  6. Mills KT et al., Comparative Effectiveness of Implementation Strategies for Blood Pressure Control in Hypertensive Patients, Annals of Internal Medicine, 2017.
  7. Reboussin DM et al., Systematic Review for the 2017 ACC/AHA High Blood Pressure Guideline, JACC, 2017.
  8. Satoh M et al., Self-measurement of blood pressure at home using a cuff device, Hypertension Research, 2024.

This article is educational and isn't billing, coding, clinical or legal advice. Check current CMS guidance and your MAC before you bill. If you want to talk through a between visit blood pressure program, book a call with Matteo.