2023 # 187 Stroke and Stroke Rehabilitation: Thrombolytic Therapy

CMS Measure ID: #187

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: No

High Priority: No

NQS Domain: Effective Clinical Care

Measure Age: > 2 years

Instructions

This measure is to be submitted for each episode of acute ischemic stroke for patients who arrive at the hospital within 3.5 hours of time last known well and for whom IV thrombolytic therapy was initiated within 4.5 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:

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 for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

Description

Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within 3.5 hours of time last known well and for whom IV thrombolytic therapy was initiated within 4.5 hours of time last known well

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: Yes
Capped at 7: Yes

Decile 0: 0 – 53.32
Decile 1: 53.33 – 85.44
Minimum: 85.45 – 93.87
Decile 3: 93.88 – 97.38
Decile 4: 97.39 – 99.43
Decile 5: 99.44 – 99.99
Decile 10: 100 – 100

Denominator

All patients aged 18 years and older with a diagnosis of acute ischemic stroke whose time of arrival is within 3.5 hours (≤ 210 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, I63.81, I63.89, I63.9

AND

Patient encounter during performance period (CPT): 99221, 99222, 99223, 99231, 99232, 99233, 99281, 99282, 99283, 99284, 99285, 99291

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02

AND

Time last known well to hospital arrival less than or equal to 3.5 hours (≤ 210 minutes)

Numerator

Patients for whom IV thrombolytic therapy was initiated at the hospital within 4.5 hours (≤ 270 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 NOTE: Updated clinical practice guidelines recommend this extended timeframe for thrombolytics, however, earlier intervention is preferred and leads to better outcomes. Patients who are eligible for thrombolytics should receive treatment as quickly as possible after arrival at the hospital.

Numerator Options:

Performance Met:

IV thrombolytic therapy initiated within 4.5 hours (≤ 270 minutes) of time last known well (G8600)

Denominator Exception:

IV thrombolytic therapy not initiated within 4.5 hours (≤ 270 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)

Performance Not Met:

IV thrombolytic therapy not initiated within 4.5 hours (≤ 270 minutes) of time last known well, reason not given (G8602)