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2021 MIPS Measure #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



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 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:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. 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 by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.



All patients with Central Venous Access (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



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

Numerator Options:

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)



Acknowledgment of the critical importance of time to reperfusion for obtaining favorable outcomes in myocardial revascularization has led to the formation of similar initiatives as a measure of effective systems to enable an endovascular treatment program for acute stroke. Multiple hospital systems must interact effectively to enable patients presenting from any location to be assessed clinically and undergo imaging to ascertain if they are candidates for endovascular therapies. By ensuring a door to puncture time of less than 2 hours, stroke patients are given the best chance of functional recovery.


Clinical Recommendation Statements

This measure is supported by the multispecialty guidelines for intra-arterial catheter directed stroke treatment published in 2013.

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