2023 # 409 Clinical Outcome Post-Endovascular Stroke Treatment

CMS Measure ID: #409

Collection Type: CQM

Reporting Frequency: Once per year

Outcome: Yes

High Priority: Yes

NQS Domain: Effective Clinical Care

Measure Age: > 2 years

Instructions

This measure is to be submitted a minimum of once per performance period for patients undergoing an endovascular stroke intervention procedure during the performance period. This measure is intended to reflect the success of the endovascular intervention inclusive of appropriate patient selection. 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. Include only patients that have cerebrovascular accidents through September 18 of the performance period. This will allow the evaluation of clinical outcome 90 days after the cerebrovascular accident within the performance period. Assessment of the mRS between 75 and 105 days is considered acceptable for reporting this measure.

Unique to this measure is the Minimum Process of Care Performance Threshold Requirement. This measure based threshold requires that at least 90% of all eligible patients have an mRS score assessed 90 days following endovascular stroke intervention. Therefore, if the performance rate for Submission Criteria 1 is below 90%, the MIPS eligible clinician would not be able to meet the denominator of the Submission Criteria 2 and this measure CANNOT BE SUBMITTED. CMS anticipates the performance rate for Submission Criteria 2 will be calculated using 100% of patients that met performance in Submission Criteria 1.

This measure contains two submission criteria which together measure the outcome following an endovascular stroke intervention. Submission Criteria 1 evaluates whether an appropriate percentage of patients received the applicable clinical follow-up assessment using mRS. Submission Criteria 2 evaluates the rate of achieving an mRS score of 0 to 2 in those patients for whom an mRS score was obtained (during clinical follow-up, Submission Criteria 1). The rate of achieving an mRS of 0 to 2 at 90 days (Submission Criteria 2) can be used to compare this measure to performance prior to the 2021 performance year, when the measure had a single performance rate. For accountability reporting in the CMS MIPS program, the rate for Submission Criteria 2 is used for performance. For the purposes of submitting this measure Data Completeness has been determined in Submission Criteria 1.

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.

THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:

1) Percentage of patients with mRS score assessed at 90 days following endovascular stroke intervention

AND

2) Percentage of patients with mRS score of 0 to 2 assessed at 90 days following endovascular stroke intervention

Description

Percentage of patients with a Modified Rankin Score (mRS) score of 0 to 2 at 90 days following endovascular stroke intervention.

Denominator

SUBMISSION CRITERIA 1:

Percentage of patients with clinical follow-up and mRS score assessed at 90 days following endovascular stroke intervention.

DENOMINATOR (SUBMISSION CRITERIA 1):

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

WITHOUT

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

SUBMISSION CRITERIA 2:

Percentage of patients with Performance Met for Submission Criteria 1 with an mRS score of 0 to 2 assessed at 90 days following endovascular stroke intervention therapy.

DENOMINATOR (SUBMISSION CRITERIA 2):

Patients with Performance Met for Submission Criteria 1 who received clinical follow-up and mRS score assessed at 90 days following endovascular stroke intervention therapy

Denominator Criteria (Eligible Cases):

Minimum Process of Care Threshold Requirement: At least 90% of all eligible patients had an mRS score assessed at 90 days following endovascular stroke intervention (G0045 submitted for Submission Criteria 1)

AND

All patients, regardless of age

AND

All eligible instances when G0045 is submitted for Performance Met (patient received clinical follow-up and mRS score assessed at 90 days) in the numerator of Submission Criteria 1

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

WITHOUT

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

Numerator

NUMERATOR (SUBMISSION CRITERIA 1):

Patients who received clinical follow-up and mRS score assessed at 90 days.

Numerator Options:

Performance Met: Clinical follow-up and mRS score assessed at 90 days following endovascular stroke intervention (G0045)

OR

Performance Not Met: Clinical follow-up and mRS score not assessed at 90 days following endovascular stroke intervention (G0046)

NUMERATOR (SUBMISSION CRITERIA 2):

Patients with Performance Met for Submission Criteria 1 with 90 day mRS score of 0-2

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 NOTE: For the purposes of submitting this measure Data Completeness has been determined in Submission Criteria 1. The performance rate calculated for Submission Criteria 2 of this measure is calculated using the subset of patients identified in the Performance Met Numerator Option of Submission Criteria 1 (G0045).

Numerator Options:

Performance Met: Patients with 90 day mRS score of 0 to 2 (G9646)

OR

Performance Not Met: Patients with 90 day mRS score greater than 2 (G9648)