#413: Door to Puncture Time for Endovascular Stroke Treatment

Quality ID

413

High Priority Measure

Yes

Specifications

Registry

Measure Type

Intermediate Outcome

Specialty

Interventional Radiology Neurosurgery

Measure description

Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours

 

Instructions

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.

Measure Submission:

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.

 

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, I63.8, I63.9

AND

Patient procedure during the performance period (CPT): 36223, 36224, 36225, 36226, 36228, 61645

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 2 hours

Numerator Options:

Performance Met: Door to puncture time of less than 2 hours (G9580)

OR

Performance Not Met: Door to puncture time of greater than 2 hours, no reason given (G9582)

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