CMS Measure ID: #413
Collection Type: CQM
Reporting Frequency: Every visit
Outcome: No
High Priority: Yes
NQS Domain: Effective Clinical Care
Measure Age: > 2 years
Instructions
This measure is to be submitted each time a patient undergoes a procedure for treatment of a cerebrovascular accident (CVA) 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:
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 undergoing endovascular stroke treatment who have a door to puncture time of 90 minutes or less.
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
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02
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 90 minutes
Numerator Options:
Performance Met:
Door to puncture time of 90 minutes or less (G9580)
OR
Performance Not Met:
Door to puncture time of greater than 90 minutes, no reason given (G9582)