2023 # 413 Door to Puncture Time for Endovascular Stroke Treatment

CMS Measure ID: #413

Collection Type: CQM, MVP

Reporting Frequency: Every visit

Outcome: No

High Priority: Yes

NQS Domain: Effective Clinical Care

Measure Age: > 2 years


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.


Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of 90 minutes or less.


All patients with CVA undergoing endovascular stroke treatment

Denominator Criteria (Eligible Cases):

All patients, regardless of age


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


Patient procedure during the performance period (CPT): 36223, 36224, 36225, 36226, 61645


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



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


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


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)


Performance Not Met:

Door to puncture time of greater than 90 minutes, no reason given (G9582)


CQM-2023, CQM-MVP-2023, MVP-2023