| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Process | No | Effective Clinical Care |
Measure Description
Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well
Instruction
This measure is to be reported for each episode of acute ischemic stroke for patients who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last knownwell. It is anticipated that eligible clinicians providing care for patients with acute ischemic stroke in the hospital setting will submit this measure.
Denominator
All patients aged 18 years and older with a diagnosis of acute ischemic stroke whose time of arrival is withintwo hours (≤ 120 minutes) of time last known well
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
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, I63.6, I63.8, I63.9
AND
Patient encounter during performance period (CPT): 99218, 99219, 99220, 99221, 99222, 99223, 99224, 99225, 99226, 99231, 99232, 99233, 99281, 99282, 99283, 99284, 99285, 99291
WITHOUT
Telehealth Modifier: GQ, GT
AND
Time last known well to arrival in the emergency department less than or equal to two hours (≤ 120 minutes)
Numerator
Patients for whom IV thrombolytic therapy was initiated at the hospital within three hours (≤ 180 minutes) of timelast known well
Definition:
Last Known Well – The date and time prior to hospital arrival at which it was witnessed or reported thatthe patient was last known to be without the signs and symptoms of the current stroke or at his or her baseline state of health.
Numerator Options:
Performance Met: IV t-PA initiated within three hours (≤ 180 minutes) of time last known well (G8600)
OR
Denominator Exception: IV t-PA not initiated within three hours (≤ 180 minutes) of time last known well for reasons documented by clinician (e.g., patient enrolled in clinical trial for stroke, patient admitted for elective carotid intervention) (G8601)
OR
Performance Not Met: IV t-PA not initiated within three hours (≤ 180 minutes) of time last known well, reason not given (G8602)