2021 MIPS Measure #413: Door to Puncture Time for Endovascular Stroke Treatment

Measure Description

Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours

Instructions

This measure is to be submitted each time a patient undergoes a procedure for treatment of a cerebral vascular accident 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.

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

AND NOT

DENOMINATOR EXCLUSIONS:

Patients who are transferred from one institution to another with a known diagnosis of CVA for endovascular stroke treatment: G9766

OR

Hospitalized patients with newly diagnosed CVA considered for endovascular stroke treatment: G9767

Numerator

Patients with CVA undergoing endovascular stroke treatment who have a door to puncture time of less than 2 hours

Numerator Options:

Performance Met:

Door to puncture time of less than 2 hours (G9580)

OR

Performance Not Met:

Door to puncture time of greater than 2 hours, no reason given (G9582)