High Priority MeasureYes
Measure TypeIntermediate Outcome
SpecialtyInterventional Radiology Neurosurgery
Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours
This measure is to be submitted each time a patient undergoes a procedure for treatment of a cerebral vascular accident during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions 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.
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, I63.8, I63.9
Patient procedure during the performance period (CPT): 36223, 36224, 36225, 36226, 36228, 61645
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 2 hours
Performance Met: Door to puncture time of less than 2 hours (G9580)
Performance Not Met: Door to puncture time of greater than 2 hours, no reason given (G9582)