Comprehensive Stroke Performance Measurement Implementation Guide

Comprehensive Stroke Performance Measurement Implementation Guide Release Notes Version: 2015Jul Release Notes Completed: June 30, 2015 Guidelines for Using Release Notes Release Notes 2015Jul provide modifications to the Comprehensive Stroke Performance Measurement Implementation Guide. The Release Notes are provided as a reference tool and are not intended to be used to program abstraction tools. Please refer to the complete and current technical specifications and abstraction information. The notes are organized to follow the order of the Table of Contents. The implementation date is 07-01-2015. Appendix A, ICD-9-CM code tables should continue to be used for discharges July 1 through September 30, 2015. Conversion of Appendix A, ICD-9 to ICD-10 code tables and data elements is effective on 10-01- 2015, unless otherwise specified. The headings are described below: Impacts - used to identify the impacted measures and portion(s) of the Manual Section. (i.e., Alphabetical Data Dictionary, Measure Information Form (MIF) and Flowchart (Algorithm)). Description of Changes - used to identify the section within the document where the change occurs, e.g., Definition, Data Collection Question, Allowable Values, and Denominator Statement - Data Elements. Rationale - provided for the change being made. Data elements that cross multiple measures and contain the same changes will be consolidated. 1

Table of Contents SECTION 1 Data Dictionary... 3 Data Element Updates... 3 SECTION 2 Measurement Information... 11 SECTION 3 Missing and Invalid Data... 14 SECTION 4 Population and Sampling Specifications... 14 SECTION 5 Data Transmission... 15 Hospital Clinical XML File Layout... 15 APPENDICES... 17 2

SECTION 1 Data Dictionary Data Element Updates Admitting Diagnosis Rationale: This change reflects the conversion of ICD-9-CM to ICD-10 codes. Definition and Suggested Data Collection Question, Allowable Values: Replace ICD-9-CM with ICD-10-CM Format: Length: 3-7 (without decimal point or dot; upper or lower case) Type: Character Allowable Values: Any valid diagnosis code as per the CMS ICD-10-CM master code table (2015 Code Descriptions in Tabular Order): http://www.cms.gov/medicare/coding/icd10/2015-icd-10-cm-and-gems.html. Elective Carotid Intervention Rationale: This change reflects the conversion of ICD-9-CM to ICD-10 codes. Inclusion and Exclusion Guidelines for Abstraction: Replace ICD-9-CM with ICD-10-PCS First Pass of a Mechanical Reperfusion Device 3

Rationale: This change is to provide additional inclusion terms for abstraction of first pass /deployment of a clot retrieval device. Inclusion Guidelines for Abstraction: Access Advance Aspiration Attempt Run ICD-10-PCS Other Procedure Times Rationale: This change is to provide abstractor clarification about time documentation for procedures performed at the bedside. For bedside procedures, e.g. external ventricular drain (EVD) placement, the time documented on the bedside flow sheet / nursing note should be used if earlier than other times documented on a procedure record or in other sources. Suggested Data Sources: Bedside flow sheet ICU notes Nursing notes Nursing flow sheet Operative notes Inclusion Guidelines for Abstraction: 1. Locate an inclusion term in a suggested data source in no particular order. Use the earliest time associated with an inclusion term that represents the ICD-10-PCS Other Procedure Time(s). 2. If no inclusion terms are found on any suggested data source, look for alternative terms associated with the procedure start time. If none are found, other sources can be used in no particular order. Use the earliest time that represents the ICD-10-PCS Other Procedure Time(s). * Procedure start * Procedure begin * Procedure initiated 4

ICD-10-PCS Principal Procedure Time Rationale: This change is to provide abstractor clarification about time documentation for procedures performed at the bedside. For bedside procedures, e.g. external ventricular drain (EVD) placement, the time documented on the bedside flow sheet / nursing note should be used if earlier than other times documented on a procedure record or in other sources. Suggested Data Sources: Bedside flow sheet ICU notes Nursing notes Nursing flow sheet Operative notes Inclusion Guidelines for Abstraction: 1. Locate an inclusion term in a suggested data source in no particular order. Use the earliest time associated with an inclusion term that represents the ICD-10-PCS Other Procedure Time(s). 2. If no inclusion terms are found on any suggested data source, look for alternative terms associated with the procedure start time. If none are found, other sources can be used in no particular order. Use the earliest time that represents the ICD-10-PCS Other Procedure Time(s). * Procedure start * Procedure begin * Procedure initiated Initial Hunt and Hess Scale Performed Rationale: This change is to provide abstractor clarification about Hunt and Hess scale documentation. The Hunt and Hess scale may be documented by the physician/apn/pa or nurse (RN). 5

Hunt and Hess obtained by teleneurology and documented in the medical record, select 'YES'. Initial Hunt and Hess Scale Time Rationale: This change is to provide abstractor clarification about Hunt and Hess scale time documentation. Add new second bullet: If the time of the first Hunt and Hess is a time prior to hospital arrival because the score was obtained by teleneurology, use the Arrival Time for the score time. Change 4 th bullet to: Initial Hunt and Hess Scale Time refers to the time that the first Hunt and Hess Scale was performed. If the time performed is mentioned in the body of a note, select the time performed rather than the time stamp on the note. If the only time documented with the scale is the time stamp on the note, then select the time stamped. Examples: o Documentation indicates that the initial Hunt and Hess scale was done at 0920. Time stamp on the note is 1159. The abstractor should select 0920 for Initial Hunt and Hess Scale Time. o Documentation indicates that the Hunt and Hess done on arrival was III. Patient arrived at your hospital 2100. Time stamp on the note is 2136. The abstractor should select 2100 for Initial Hunt and Hess Scale Time. o Hunt & Hess 3 [no time] documented. Time stamp on the note is 1513. The abstractor should select 1513 for Initial Hunt and Hess Scale Time. Initial ICH Score Performed Rationale: This change is to provide abstractor clarification about ICH score documentation. The ICH score may be documented by the physician/apn/pa or nurse (RN). ICH score obtained by teleneurology and documented in the medical record, select 'YES'. If a total ICH score (i.e., sum of the component points) is documented, select YES. 6

If components are scored but the total ICH score is not documented or left blank, select NO. Do not infer a total ICH score from documented component scores. Initial ICH Score Time Rationale: This change is to provide abstractor clarification about ICH score time documentation. Add new second bullet: If the time of the first ICH score is a time prior to hospital arrival because the score was obtained by teleneurology, use the Arrival Time for the score time. Change 4th bullet to: Initial ICH Score Time refers to the time that the first ICH score was performed. If the time performed is mentioned in the body of a note, select the time performed rather than the time stamp on the note. If the only time documented with the score is the time stamp on the note, then select the time stamped. Examples: o Documentation indicates that the initial ICH score was done at 0920. Time stamp on the note is 1159. The abstractor should select 0920 for Initial ICH Score Time. o Documentation indicates that the ICH score done on arrival was 5. Patient arrived at your hospital 2100. Time stamp on the note is 2136. The abstractor should select 2100 for Initial ICH Score Time. o ICH score 5 [no time] documented. Time stamp on the note is 1513. The abstractor should select 1513 for Initial ICH Score Time. Initial NIHSS Score Time Rationale: This change is to provide abstractor clarification about NIHSS score time documentation. Add new second bullet: If the time of the first NIHSS score is a time prior to hospital arrival because the score was obtained by teleneurology, use the Arrival Time for the score time. Change 4 th bullet to: Initial NIHSS Score Time refers to the time that the first NIHSS score was performed. If the time performed is mentioned in the body of a note, select the time performed rather than the time stamp on the note. If the only time documented with the score is the time stamp on the note, then select the time stamped. Examples: 7

o Documentation indicates that the initial NIHSS score was done at 0920. Time stamp on the note is 1159. The abstractor should select 0920 for Initial NIHSS Score Time. o Documentation indicates that the NIHSS score done on arrival was 12. Patient arrived at your hospital 2100. Time stamp on the note is 2136. The abstractor should select 2100 for Initial NIHSS Score Time. o NIHSS score 12 [no time] documented. Time stamp on the note is 1513. The abstractor should select 1513 for Initial NIHSS Score Time. Nimodipine Administration Rationale: This change is to include an oral suspension form of nimodipine (Nymalize), FDA approved in May, 2013, as an inclusion term for abstraction, and provide clarification about the timeframe for abstraction of nimodipine administration. Nimodipine treatment must be administered at this hospital within the first 24 hours of arrival to select 'YES'. It is not necessary to review documentation outside of this timeframe. If nimodipine was administered at another hospital and the patient was subsequently transferred to this hospital and nimodipine treatment continued on admission to this hospital, select YES' If nimodipine was administered at this hospital later than the first 24 hours after arrival, select 'NO'. If nimodipine was administered at another hospital and the patient was subsequently transferred to this hospital and nimodipine treatment was not resumed or discontinued, select 'NO'. A physician order for nimodipine that is not executed, select NO'. Inclusion Guidelines for Abstraction: Nymalize Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Rationale: This change is to provide abstractor clarification about TICI documentation. The TICI grade may be documented by the physician/apn/pa, or a nurse (RN), circulating nurse, or operating room technician designated to scribe during the procedure. 8

When multiple TICIs are documented because more than one vessel or branches of an artery are occluded, select the TICI grade associated with the site of primary vessel occlusion. If unable to determine whether the TICI reflects reperfusion of the primary vessel, then select "UTD". Proximal or Distal Occlusion Rationale: This change is to increase the accuracy for abstraction of proximal clots associated with higher risk and poorer outcomes. Definition: Documentation in the medical record of the location of the clot in either the large arteries in the neck or base of the brain (proximal), or small arteries higher up in the brain (distal). Arterial occlusions arising more proximally are associated with poorer outcomes. Allowable Values: 1 Proximal cerebral occlusion 2 Distal cerebral occlusion 3 Neither proximal or distal, OR unable to determine (UTD) from the medical record documentation If the occlusion is documented in an artery listed as an inclusion term for "proximal", select 1. If the occlusion is documented in an artery listed as an inclusion term for "distal", select 2. If multiple occlusions, select "proximal" or "distal" for the primary vessel occlusion. If unable to determine, select 3. Inclusion Guidelines for Abstraction: PROXIMAL: Internal Carotid Artery (ICA) ICA terminus Middle Cerebral Artery (MCA) Middle Cerebral Artery (MCA) M1 segment 9

M1 T-occlusion (T-lesion) Vertebral Artery Basilar Artery DISTAL: Anterior Cerebral Artery (ACA) Anterior Cerebral Artery (ACA) A1 segment A1 Anterior Cerebral Artery (ACA) A2 segment A2 Anterior Cerebral Artery (ACA) A3 segment A3 Middle Cerebral Artery (MCA) M2 segment M2 Middle Cerebral Artery (MCA) M3 segment M3 Middle Cerebral Artery (MCA) M4 segment M4 Posterior Cerebral Artery (PCA) Posterior Cerebral Artery (PCA) P1 segment P1 Posterior Cerebral Artery (PCA) P2 segment P2 Posterior Cerebral Artery (PCA) P3 segment P3 Reason for Not Administering Nimodipine Treatment Rationale: This change is to provide stand-alone reasons for not administering nimodipine. Definition: Non-aneurysmal subarachnoid hemorrhage (SAH) Reversible cerebral vasoconstriction syndrome Cerebral amyloid angiopathy 10

The following are acceptable as stand-alone reasons for not administering nimodipine treatment Nimodipine linkage is not needed: o Non-aneurysmal subarachnoid hemorrhage (SAH) o Reversible cerebral vasoconstriction syndrome o Cerebral amyloid angiopathy Site of Primary Vessel Occlusion Rationale: Correct typos. Format Length: 2 Allowable Values 4 Internal carotid artery (ICA) 5 ICA terminus (T-lesion; T-occlusion) SECTION 2 Measurement Information CSTK-03 Rationale: This change completes the list of data elements included in the denominator. Data Elements: Add ICD-9-CM Other Diagnosis Codes CSTK-03, CSTK-04 Rationale: This change updates references to reflect current evidence. Selected References: Add Hemphill JC III, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald L, Mitchell PH, Scott PA, Selim MH, Woo D. Guidelines for the management of spontaneous intracerebral hemorrhage:a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:1-29. 11

CSTK-04 Rationale: This change removes SAH patients from the denominator population. Included Populations: Change Appendix A, Table 8.2 to Appendix A, Table 8.2b CSTK-04 Algorithm Rationale: This change selects only those cases with a principal diagnosis code on table 8.2b; also swaps data element INR Value > 1.4 and Clinical Trial position in order to reduce data collection burden. Change ICD-10-CM Principal Diagnosis Code data element o Change downward branch label to On Table 8.2b o Change rightward branch label to Not on Table 8.2b Move data element INR Value > 1.4 below data element Clinical Trial. No branch label or logic change Move data element Comfort Measures Only below ICD-10-CM Principal Diagnosis Code. No branch label or logic change CSTK-05 Algorithm Rationale: This change re-defines the algorithm label in order to prioritize the branch and flow the case to the correct direction. Connector J 2 nd ICD-10-PCS Principal or Other Procedure Codes data element Change downward branch label to None on Table 8.1b Change rightward branch label to Any on Table 8.1b Connector ab ICD-10-PCS Principal or Other Procedure Codes data element Change downward branch label to None on Table 8.1b Change rightward branch label to Any on Table 8.1b 12

CSTK-06 Rationale: This change removes Nimotop from the rationale for the measure because it is no longer the only trade name for nimodipine. An oral suspension of nimodipine (Nymalize) is also available. Rationale: Remove the word Nimotop from paragraph two, first bullet. CSTK-06 Algorithm Rationale: This change swaps data element position of Comfort Measures Only and Clinical Trial to be consistent with the CSTK-04 algorithm. Move data element Comfort Measures Only below ICD-10-CM Principal Diagnosis Code data element. No branch label or logic change Move data element Clinical Trial below Comfort Measures Only data element. No branch label or logic change CSTK-IPP, CSTK-01, CSTK- 02, CSTK-03, CSTK-04, CSTK-05, CSTK-06, CSTK-07, CSTK-08 Algorithms Rationale: This change reflects diagnosis and procedure code terminology changes Replace ICD-9-CM Principal Diagnosis Code to ICD-10-CM Principal Diagnosis Code Replace ICD-9-CM Other Diagnosis Codes to ICD-10-CM Other Diagnosis Codes Replace ICD-9-CM Principal or Other Procedure Codes to ICD-10-PCS Principal or Other Procedure Codes Replace ICD-9-CM Principal or Other Procedure Dates to ICD-10-PCS Principal or Other Procedure Dates Replace ICD-9-CM Principal or Other Procedure Times to ICD-10-PCS Principal or Other Procedure Times CSTK-02, CSTK-05, CSTK-07, CSTK-08 Rationale: This change updates references to reflect current evidence. 13

Selected References: Add Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et. al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. NEJM. 2015 Mar;372(11): 1009-17. Demchuk AM, Goyal M, Monon BK, Eesa M, Ryckborst KJ, Kamal N, et. al. Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times (ESCAPE) trial: methodology. Int J Stroke. 2015 Apr;10(3): 429-38. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et. al. Stentretriever thrombectomy after intravenous t-pa vs. t-pa alone in stroke. NEJM. 2015 Apr: 1-11. Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A, et. al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014 May;694): 260-4. SECTION 3 Missing and Invalid Data Rationale: This change reflects diagnosis and procedure code terminology changes Replace ICD-9-CM Principal and Other Diagnosis Code to ICD-10-CM Principal and Other Diagnosis Code Replace ICD-9-CM Principal Diagnosis Codes to ICD-10-CM Principal Diagnosis Codes Replace ICD-9-CM Other Diagnosis Codes to ICD-10-CM Other Diagnosis Codes Replace ICD-9-CM Principal or Other Procedure Codes to ICD-10-PCS Principal or Other Procedure Codes SECTION 4 Population and Sampling Specifications Rationale: This change reflects diagnosis and procedure code terminology changes Replace ICD-9-CM Principal Diagnosis Code to ICD-10-CM Principal Diagnosis Code 14

Replace ICD-9-CM Procedure Codes to ICD-10-PCS Procedure Codes Replace ICD-9-CM Diagnosis Codes to ICD-10-CM Diagnosis Codes Replace ICD-9-CM Principal and Other Diagnosis Code to ICD-10-CM Principal and Other Diagnosis Code SECTION 5 Data Transmission Rationale: This change reflects diagnosis and procedure code terminology changes Replace ICD-9-CM Principal Diagnosis Code to ICD-10-CM Principal Diagnosis Code Replace ICD-9-CM Principal Procedure Codes to ICD-10-PCS Principal Procedure Codes Replace ICD-9-CM Other Diagnosis Codes to ICD-10-CM Other Diagnosis Codes Replace ICD-9-CM Other Procedure Codes to ICD-10-PCS Other Procedure Codes Hospital Clinical XML File Layout Admitting Diagnosis Rationale: This change reflects diagnosis and procedure code terminology changes Changed the Answer value and Field size to accommodate the ICD-10 Diagnosis codes format and length Proximal or Distal Occlusion Rationale: To reflect changes made to the data element allowable values and correcting the typing error in the element name in the XML layout document Hospital Clinical Data Detail Elements Information Change Answer Value 1, 2, 3 to 15

1 Proximal cerebral occlusion 2 Distal cerebral occlusion 3 Neither proximal or distal, OR unable to determine (UTD) from the medical record documentation Site of Primary Vessel Occlusion Rationale: To reflect changes made to the data element allowable values Field Size 2 Allowable Values 4 Internal carotid artery (ICA) 5 ICA terminus (T-lesion; T-occlusion) ICD-9-CM Principal Diagnosis Code ICD-9-CM Other Diagnosis Codes ICD-9-CM Principal Procedure Code ICD-9-CM Other Procedure Codes ICD-9-CM Principal Procedure Date ICD-9-CM Other Procedure Dates ICD-9-CM Principal Procedure Time ICD-9-CM Other Procedure Times Rationale: These changes reflects diagnosis and procedure code terminology changes Changed the Question (Names) to reflect ICD-10 Changed the Answer value and Field size to accommodate the ICD-10 Diagnosis codes format and length Changed Suggested Data Collection Question to reflect ICD-10 16

APPENDICES Appendix A ICD-10 Code Tables CSTK-03 Rationale: This change adds ICD-10-PCS codes equivalent to ICD-9-CM Other Craniectomy to Table 8.2e. Table 8.2e Surgical Intervention Procedures 0N500ZZ Destruction of Skull, Open Approach 0N503ZZ Destruction of Skull, Percutaneous Approach 0N504ZZ Destruction of Skull, Percutaneous Endoscopic Approach 0N510ZZ Destruction of Right Frontal Bone, Open Approach 0N513ZZ Destruction of Right Frontal Bone, Percutaneous Approach 0N514ZZ Destruction of Right Frontal Bone, Percutaneous Endoscopic Approach 0N520ZZ Destruction of Left Frontal Bone, Open Approach 0N523ZZ Destruction of Left Frontal Bone, Percutaneous Approach 0N524ZZ Destruction of Left Frontal Bone, Percutaneous Endoscopic Approach 0N530ZZ Destruction of Right Parietal Bone, Open Approach 0N533ZZ Destruction of Right Parietal Bone, Percutaneous Approach 0N534ZZ Destruction of Right Parietal Bone, Percutaneous Endoscopic Approach 0N540ZZ Destruction of Left Parietal Bone, Open Approach 0N543ZZ Destruction of Left Parietal Bone, Percutaneous Approach 0N544ZZ Destruction of Left Parietal Bone, Percutaneous Endoscopic Approach 0N550ZZ Destruction of Right Temporal Bone, Open Approach 0N553ZZ Destruction of Right Temporal Bone, Percutaneous Approach 0N554ZZ Destruction of Right Temporal Bone, Percutaneous Endoscopic Approach 0N560ZZ Destruction of Left Temporal Bone, Open Approach 0N563ZZ Destruction of Left Temporal Bone, Percutaneous Approach 0N564ZZ Destruction of Left Temporal Bone, Percutaneous Endoscopic Approach 0N570ZZ Destruction of Right Occipital Bone, Open Approach 0N573ZZ Destruction of Right Occipital Bone, Percutaneous Approach 0N574ZZ Destruction of Right Occipital Bone, Percutaneous Endoscopic Approach 0N580ZZ Destruction of Left Occipital Bone, Open Approach 0N583ZZ Destruction of Left Occipital Bone, Percutaneous Approach 0N584ZZ Destruction of Left Occipital Bone, Percutaneous Endoscopic Approach 0NB00ZZ Excision of Skull, Open Approach 0NB03ZZ Excision of Skull, Percutaneous Approach 17

0NB04ZZ 0NB10ZZ 0NB13ZZ 0NB14ZZ 0NB20ZZ 0NB23ZZ 0NB24ZZ 0NB30ZZ 0NB33ZZ 0NB34ZZ 0NB40ZZ 0NB43ZZ 0NB44ZZ 0NB50ZZ 0NB53ZZ 0NB54ZZ 0NB60ZZ 0NB63ZZ 0NB64ZZ 0NB70ZZ 0NB73ZZ 0NB74ZZ 0NB80ZZ 0NB83ZZ 0NB84ZZ 0NT10ZZ 0NT20ZZ 0NT30ZZ 0NT40ZZ 0NT50ZZ 0NT60ZZ 0NT70ZZ 0NT80ZZ Excision of Skull, Percutaneous Endoscopic Approach Excision of Right Frontal Bone, Open Approach Excision of Right Frontal Bone, Percutaneous Approach Excision of Right Frontal Bone, Percutaneous Endoscopic Approach Excision of Left Frontal Bone, Open Approach Excision of Left Frontal Bone, Percutaneous Approach Excision of Left Frontal Bone, Percutaneous Endoscopic Approach Excision of Right Parietal Bone, Open Approach Excision of Right Parietal Bone, Percutaneous Approach Excision of Right Parietal Bone, Percutaneous Endoscopic Approach Excision of Left Parietal Bone, Open Approach Excision of Left Parietal Bone, Percutaneous Approach Excision of Left Parietal Bone, Percutaneous Endoscopic Approach Excision of Right Temporal Bone, Open Approach Excision of Right Temporal Bone, Percutaneous Approach Excision of Right Temporal Bone, Percutaneous Endoscopic Approach Excision of Left Temporal Bone, Open Approach Excision of Left Temporal Bone, Percutaneous Approach Excision of Left Temporal Bone, Percutaneous Endoscopic Approach Excision of Right Occipital Bone, Open Approach Excision of Right Occipital Bone, Percutaneous Approach Excision of Right Occipital Bone, Percutaneous Endoscopic Approach Excision of Left Occipital Bone, Open Approach Excision of Left Occipital Bone, Percutaneous Approach Excision of Left Occipital Bone, Percutaneous Endoscopic Approach Resection of Right Frontal Bone, Open Approach Resection of Left Frontal Bone, Open Approach Resection of Right Parietal Bone, Open Approach Resection of Left Parietal Bone, Open Approach Resection of Right Temporal Bone, Open Approach Resection of Left Temporal Bone, Open Approach Resection of Right Occipital Bone, Open Approach Resection of Left Occipital Bone, Open Approach CSTK-03 Rationale: This change adds an ICD-9-CM procedure code to Table 8.2e. Table 8.2e Surgical Intervention Procedures 18

01.25 Other craniectomy CSTK-03 Rationale: This change excludes patients with specified ICD-10-CM codes from the denominator population. Table 8.2f Traumatic Brain Injury Q283 Other Malformations of Cerebral Vessels I67841 Reversible Cerebrovascular Vasoconstriction Syndrome I680 Cerebral Amyloid Angiopathy CSTK-03 Rationale: This change excludes patients with specified ICD-9-CM codes from the denominator population. Table 8.2f Traumatic Brain Injury 435.9 Unspecified transient cerebral ischemia 437.8 Other ill-defined cerebrovascular disease 747.81 Other malformations of cerebral vessels 19