* Measure #10: Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Reports

2009 PQRI REPORTING OPTIONS: CLAIMS-BASED, REGISTRY

DESCRIPTION:

Percentage of final reports for CT or MRI studies of the brain performed within 24 hours of arrival to the hospital for patients aged 18 years and older with either a diagnosis of ischemic stroke or transient ischemic attack (TIA) or intracranial hemorrhage or at least one documented symptom consistent with ischemic stroke or TIA or intracranial hemorrhage that includes documentation of the presence or absence of each of the following: hemorrhage and mass lesion and acute infarction

INSTRUCTIONS:

This measure is to be reported each time a CT or MRI is performed in a hospital or outpatient setting during the reporting period for patients with a diagnosis or symptom of ischemic stroke, TIA, or intracranial hemorrhage. In the event the CT or MRI is performed in an outpatient imaging center, this satisfies the clinical action described in CPT II 3111F. Arrival at the outpatient imaging center where the CT or MRI study is being performed will be considered as "arrival to the hospital". It is anticipated that clinicians who provide the physician component of diagnostic imaging studies for patients with stroke, TIA, or intracranial hemorrhage in the hospital or outpatient setting will submit this measure. Note: Use of symptom codes is limited to those specified in the denominator coding.

Measure Reporting via Claims:

Line-item ICD-9-CM diagnosis (includes symptom codes), CPT codes, and patient demographics are used to identify patients who are included in the measure's denominator. CPT Category II codes are used to report the numerator of the measure.

When reporting the measure via claims, submit the listed ICD-9-CM diagnosis (including symptom codes), CPT codes, and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier. The reporting modifier allowed for this measure is: 8P- reason not otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.

NUMERATOR:

Final reports of the initial CT or MRI that include documentation of the presence or absence of each of the following: hemorrhage and mass lesion and acute infarction

Numerator Instructions: Studies (CT or MRI) performed at an outpatient imaging center within 24 hours will be considered as "arrival to the hospital".

Definition: Equivalent terms or synonyms for hemorrhage, mass lesion, or infarction, if documented in the CT or MRI report, would meet the measure

NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on the claim form in order to properly report this measure. The "correct combination" of codes may require the submission of multiple numerator codes.

Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Presence/Absence of Hemorrhage, Mass Lesion, and Acute Infarction Documented

(Two CPT II codes [3110F & 3111F] are required on the claim form to submit this numerator option)

CPT II 3110F: Presence or absence of hemorrhage and mass lesion and acute infarction documented in final CT or MRI report

AND

CPT II 3111F: CT or MRI of the brain performed within 24 hours of arrival to the hospital

OR

If patient is not eligible for this measure because CT or MRI of the brain was performed greater than 24 hours after arrival to the hospital, report:

(One CPT II code [3112F] is required on the claim form to submit this numerator option)

CPT II 3112F: CT or MRI of the brain performed greater than 24 hours after arrival to the hospital

OR

Presence/Absence of Hemorrhage, Mass Lesion, and Acute Infarction not Documented, Reason not Specified

(Two CPT II codes [3110F-8P & 3111F] are required on the claim form to submit this numerator option)

Append a reporting modifier (8P) to CPT Category II code 3110F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified.

3110F with 8P: Presence or absence of hemorrhage and mass lesion and acute infarction was not documented in final CT or MRI report, reason not otherwise specified

AND

CPT II 3111F: CT or MRI of the brain performed within 24 hours of arrival to the hospital

DENOMINATOR:

All final reports for CT or MRI studies of the brain performed within 24 hours of arrival to the hospital for patients aged 18 years and older with either a diagnosis of ischemic stroke or TIA or intracranial hemorrhage OR at least one documented symptom consistent with ischemic stroke or TIA or intracranial hemorrhage

Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter

AND

For purposes of this measure, the listed symptoms will be considered "documented symptoms consistent" with ischemic stroke or TIA or intracranial hemorrhage. Each of the listed symptoms corresponds to a specific ICD-9-CM code in the code table below.

Note: Use of symptom codes is limited to the following:


  • Transient visual loss (368.12)
  • Diplopia (double vision) (368.2)
  • Vertigo of central origin (386.2)
  • Transient global amnesia (437.7)
  • Transient alteration of awareness (780.02)
  • Lack of coordination (781.3)
  • Transient paralysis of limb (781.4)
  • Facial weakness (781.94)
  • Disturbance of skin sensation (782.0)
  • Aphasia (784.3)
  • Slurred speech (784.5)

Diagnosis for ischemic stroke or TIA or intracranial hemorrhage – including symptom codes (line-item ICD-9-CM): 368.12, 368.2, 386.2, 431, 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91, 435.0, 435.1, 435.2, 435.3, 435.8, 435.9, 437.7, 780.02, 781.3, 781.4, 781.94, 782.0, 784.3, 784.5

AND

Patient encounter during the reporting period (CPT): 0042T, 70450, 70460, 70470, 70551, 70552, 70553

RATIONALE:

The CT and MRI findings are critical to initiating care for the patient with stroke. All CT and MRI reports should address the presence or absence of these three important findings. This documentation is particularly vital in the report of the first imaging study performed after arrival at the hospital, on which initial treatment decisions will be based.

CLINICAL RECOMMENDATION STATEMENTS:

Brain imaging is required to guide acute intervention. (Grade A) There is a uniform agreement that CT accurately identifies most cases of intracranial hemorrhage and helps discriminate nonvascular causes of neurological symptoms, e.g., brain tumor. (Grade B) With the advent of rtPA treatment, interest has grown in using CT to identify subtle, early signs of ischemic brain injury (early infarct signs) or arterial occlusion that might affect decisions about treatment. The presence of these signs is associated with poor outcomes. (Adams, ASA, 2003) (Class A)

A technically adequate head CT scan is required prior to administration of thrombolytic therapy to exclude brain hemorrhage and nonischemic diagnoses. The baseline CT scan is also sensitive for detection of early signs of cerebral infarction. Subtle or limited signs of early infarction on the CT scan are common even within the first 3 h of stroke evolution.

Preliminary data suggest that specific MRI profiles may identify patients who are particularly likely to benefit from thrombolytic therapy. New MRI techniques including perfusion-weighted and diffusion-weighted may detect ischemic injury in the first hour and may reveal the extent of reversible and irreversible injury. In addition, MRI appears to be highly sensitive for identification of acute brain hemorrhage. (Albers, ACCP, 2004)