2026 MIPS Measure #187: Stroke and Stroke Rehabilitation: Thrombolytic Therapy

Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within 3.5 hours of time last known well and for whom IV thrombolytic therapy was initiated within 4.5 hours of time last known well.

This measure is to be submitted for each episode of acute ischemic stroke for patients who arrive at the hospital within 3.5 hours of time last known well and for whom IV thrombolytic therapy was initiated within 4.5 hours of time last known well. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians providing care for patients with acute ischemic stroke in the hospital setting will submit this measure.

All patients aged 18 years and older with a diagnosis of acute ischemic stroke whose time of arrival is within 3.5 hours (? 210 minutes) of time last known well

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, I63.81, I63.89, I63.9

AND

Patient encounter during performance period (CPT): 99221, 99222, 99223, 99231, 99232, 99233, 99281, 99282, 99283, 99284, 99285, 99291

WITHOUT

Encounters conducted via telehealth: M1426

AND

Time last known well to hospital arrival less than or equal to 3.5 hours (? 210 minutes): M1438

Patients for whom IV thrombolytic therapy was initiated at the hospital within 4.5 hours (? 270 minutes) of time last known well

Last Known Well – The date and time prior to hospital arrival at which it was witnessed or reported that the 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 NOTE: Current clinical practice guidelines recommend this extended timeframe for thrombolytics, however, earlier intervention is preferred and leads to better outcomes. Patients who are eligible for thrombolytics should receive treatment as quickly as possible after arrival at the hospital.

Performance Met: IV thrombolytic therapy initiated within 4.5 hours (? 270 minutes) of time last known well (G8600)

OR

Denominator Exception: IV thrombolytic therapy not initiated within 4.5 hours (? 270 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 thrombolytic therapy not initiated within 4.5 hours (? 270 minutes) of time last known well, reason not given (G8602)

One trial (ECASS III) specifically evaluating the efficacy of IV alteplase within 3 and 4.5 hours after symptom onset and pooled analysis of multiple trials testing IV alteplase within various time windows support the efficacy of IV alteplase up to 4.5 hours after symptom onset. European Cooperative Acute Stroke Study (ECASS) III excluded octogenarians, patients taking warfarin regardless of international normalized ratio, patients with combined history of diabetes mellitus and previous ischemic stroke, and patients with very severe strokes (National Institutes of Health Stroke Scale [NIHSS] score >25) because of a perceived excessive risk of intracranial hemorrhage in those cases. However, careful analysis of available published data summarized in an AHA/American Stroke Association (ASA) scientific statement indicates that these exclusion criteria from the trial may not be justified in practice.

The Efficacy and Safety of MRI-based Thrombolysis in Wake-Up Stroke (WAKE-UP) random control trial randomized 503 patients with AIS who awoke with stroke or had unclear time of onset and could be treated with IV alteplase within 4.5 hours of stroke symptom recognition. Eligibility required magnetic resonance imaging (MRI) mismatch between abnormal signal on diffusion-weighted magnetic resonance imaging (DW-MRI) and no visible signal change on fluid-attenuated inversion recovery (FLAIR). DW-MRI lesions larger than one-third of the territory of the middle cerebral artery (MCA), NIHSS score > 25, contraindication to treatment with alteplase, or planned thrombectomy were all exclusions. Ninety-four percent were wake-up strokes. Median NIHSS score was 6. Median time from last known well to symptom recognition was ?7 hours and to alteplase administration slightly over 10 hours. The primary end point of a modified Rankin Scale (mRS) score 0 to 1 at 90 days was achieved in 53.3% of the alteplase group and in 41.8% of the placebo group (P=0.02). Only 20% had large vessel occlusion (LVO) of the intracranial internal carotid or proximal middle cerebral arteries.

Reference: Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL; on behalf of the American Heart Association Stroke Council. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50:e344–e418 doi: 10.1161/STR.0000000000000211. Available at: https://www.ahajournals.org/doi/abs/10.1161/STR.0000000000000211.