2021 MIPS Measure #187: Stroke and Stroke Rehabilitation: Thrombolytic Therapy

Measure Description

Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well

Instructions

This measure is to be submitted for each episode of acute ischemic stroke for patients who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well. It is anticipated that eligible clinicians providing care for patients with acute ischemic stroke in the hospital setting will submit this measure.

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 aged 18 years and older with a diagnosis of acute ischemic stroke whose time of arrival is within two hours (≤ 120 minutes) of time last known well

Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter

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, I63.6, I63.8, I63.9

AND

Patient encounter during performance period (CPT): 99218, 99219, 99220, 99221, 99222, 99223, 99224,99225, 99226, 99231, 99232, 99233, 99281, 99282, 99283, 99284, 99285, 99291

WITHOUT

Telehealth Modifier: GQ, GT, 95, POS 02

AND
Time last known well to arrival in the emergency department less than or equal to two hours (≤ 120 minutes)

Numerator

Patients for whom IV thrombolytic therapy was initiated at the hospital within three hours (≤ 180 minutes) of time last known well

Definition:

Last Known Well – The date and time prior to hospital arrival at which it was witnessed or reported that the patient was last known to be without the signs and symptoms of the current stroke or at his or her baseline state of health.

Numerator Options:

Performance Met:

IV t-PA initiated within three hours (≤ 180 minutes) of time last known well (G8600)

OR

Denominator Exception:

IV alteplase not initiated within three hours (≤ 180 minutes) of time last known well for reasons documented by clinician (e.g. patient enrolled in clinical trial for stroke, patient admitted for elective carotid intervention, patient received tenecteplase (TNK))(G8601)

OR

Performance Not Met:

IV t-PA not initiated within three hours (≤ 180 minutes) of time last known well, reason not given (G8602)