2021 MIPS Measure #409: Clinical Outcome Post Endovascular Stroke Treatment

Measure Description

Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention

Instructions

This measure is to be submitted each time an endovascular stroke intervention procedure is performed during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: Include only patients that have cerebrovascular accidents through September 30 of the performance period. This will allow the evaluation of at least 90 days after the cerebrovascular accident within the performance period.

Measure Submission Type:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

Denominator

All patients with CVA undergoing endovascular stroke treatment

Denominator Criteria (Eligible Cases):

All patients, regardless of age

AND

Diagnosis for ischemic stroke (ICD-10-CM): I63.00, I63.011, I63.012, I63.013, I63.019, I63.02, I63.031, I63.032, I63.033, I63.039, I63.09, I63.10, I63.111, I63.112, I63.113, I63.119, I63.12, I63.131, I63.132, I63.133, I63.139, I63.19, I63.20, I63.211, I63.212, I63.213, I63.219, I63.22, I63.231, I63.232, I63.233, I63.239, I63.29, I63.30, I63.311, I63.312, I63.313, I63.319, I63.321, I63.322, I63.323, I63.329, I63.331, I63.332, I63.333, I63.339, I63.341, I63.342, I63.343, I63.349, I63.39, I63.40, I63.411, I63.412, I63.413, I63.419, I63.421, I63.422, I63.423, I63.429, I63.431, I63.432, I63.433, I63.439, I63.441, I63.442, I63.443, I63.449, I63.49, I63.50, I63.511, I63.512, I63.513, I63.519, I63.521, I63.522, I63.523, I63.529, I63.531, I63.532, I63.533, I63.539, I63.541, I63.542, I63.543, I63.549, I63.59, I63.81, I63.89, I63.9

AND

Patient procedure during the performance period (CPT): 36223, 36224, 36225, 36226, 61645

Numerator

Patients with a mRs of 0 to 2 at 90 days

Definition:

The Modified Rankin Scale (mRS) –

The scale runs from 0-6, running from perfect health without symptoms to death.

• 0 – No symptoms
• 1 – No significant disability. Able to carry out all usual activities, despite some symptoms
• 2 – Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities
• 3 – Moderate disability. Requires some help, but able to walk unassisted
• 4 – Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted
• 5 – Severe disability. Requires constant nursing care and attention, bedridden, incontinent
• 6 – Dead

Numerator Options:

Performance Met:

Patients with 90 day mRs score of 0 to 2 (G9646)

OR

Denominator Exception:

Patients in whom mRs score could not be obtained a 90 day follow-up (G9647)

OR

Performance Not Met:

Patients with 90 day mRs score greater than 2 (G9648)