* Measure #31: Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis (DVT) for Ischemic Stroke or Intracranial Hemorrhage
2009 PQRI REPORTING OPTIONS: CLAIMS-BASED, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who received DVT prophylaxis by end of hospital day two
INSTRUCTIONS:
This measure is to be reported during each hospital stay when a patient is under active treatment for ischemic stroke or intracranial hemorrhage during the reporting period. Part B claims data will be analyzed to determine a hospital stay. If multiple qualifying diagnoses are submitted on the same claim form, only one instance of reporting will be counted. It is anticipated that clinicians who care for patients with a diagnosis of ischemic stroke or intracranial hemorrhage in the hospital setting will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis 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 codes, CPT codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
NUMERATOR:
Patients who received Deep Vein Thrombosis (DVT) prophylaxis by the end of hospital day two
Definition:
DVT Prophylaxis – Can include Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), intravenous Heparin, low-dose subcutaneous heparin, or intermittent pneumatic compression devices.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
DVT Prophylaxis ReceivedCPT II 4070F: Deep Vein Thrombosis (DVT) prophylaxis received by end of hospital day 2
OR
DVT Prophylaxis not Received for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4070F to report documented circumstances that appropriately exclude patients from the denominator.
4070F with 1P: Documentation of medical reason(s) for not receiving DVT Prophylaxis by end of hospital day 2, including physician documentation that patient is ambulatory
4070F with 2P: Documentation of patient reason(s) for not receiving DVT Prophylaxis by end of hospital day 2
OR
DVT Prophylaxis not Received, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4070F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified.
4070F with 8P: Deep Vein Thrombosis (DVT) prophylaxis was not received by end of hospital day 2, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for ischemic stroke or intracranial hemorrhage (line-item ICD-9-CM): 431, 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91
AND
Patient encounter during the reporting period (CPT): 99221, 99222, 99223, 99251, 99252, 99253, 99254, 99255, 99291
RATIONALE:
Patients on bed rest are at high risk for deep vein thrombosis. DVT prevention is important for all patients who have suffered a stroke or an intracranial hemorrhage and may have decreased mobility. The intent of this measure is to assure that adequate DVT prophylaxis is received for either diagnosis. As noted in the clinical recommendation statements, the appropriate type of prophylaxis differs by diagnosis. Anticoagulants are generally contraindicated in patients with intracranial hemorrhage. These patients are still at risk for DVT so they should receive prophylaxis with mechanical devices. Low-dose subcutaneous heparin may be initiated on the second day after onset of the hemorrhage.
CLINICAL RECOMMENDATION STATEMENTS:
Subcutaneous unfractionated heparin, LMW heparins, and heparinoids may be considered for DVT prophylaxis in at-risk patients with acute ischemic stroke, recognizing that nonpharmacologic treatments for DVT prevention also exist. (Coull, AAN/ASA, 2002) (Grade A)
The use of intermittent external compression stockings or aspirin for patients who cannot receive anticoagulants is strongly recommended to prevent deep vein thrombosis among immobilized patients. (Adams, ASA, 2003) (Grades A and B)
For acute stroke patients with restricted mobility, it is recommended prophylactic low-dose subcutaneous heparin or low-molecular-weight heparins or heparinoid. (Grade 1A) In patients with an acute ICH, it is recommended the initial use of intermittent pneumatic compression for the prevention of DVT and PE. (Grade 1C+) In stable patients, we suggest low-dose subcutaneous heparin may be initiated as soon as the second day after the onset of the hemorrhage. (Grade 2C) (Albers, ACCP, 2004)
