2022 MIPS Measure #413: Door to Puncture Time for Endovascular Stroke Treatment

Measure Description

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

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:

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.

Denominator

All patients with cerebrovascular accident (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: 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)

Rationale

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 90 minutes or less, 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 and updated in 2018 (1, 2, 3).

1. Sacks D. et al. Society of Interventional Radiology Multisociety Consensus Quality Improvement Guidelines For Intraarterial Catheter-Directed Treatment Of Acute Ischemic Stroke. J Vasc Interv Radiol. 2013; 24: 151-163
2. Sacks, D. et al. Society of Interventional Radiology Multisociety Consensus QualityImprovement Revised Consensus Statement for Endovascular Therapy of Acute Ischemic Stroke J Vasc Interv Radiol 2018; 29:441–453
3. Multisociety consensus quality improvement guidelines for intraarterial catheter-directed treatment of acute ischemic strokeJ Vasc Interv Radiol. 2013 Feb;24(2):151-63. Epub 2013 Jan 28.