Specifications Manual for Joint Commission National Quality Measures (v2020B)
Posted: 2/5/2020
Home » Highest NIHSS Score Documented Within 36 Hours Following IA Alteplase or MER Initiation

Release Notes:
Data Element
Version 2020B

Name:Highest NIHSS Score Documented Within 36 Hours Following IA Alteplase or MER Initiation
Collected For: CSTK-05
Definition:The highest NIHSS score documented within 36 hours following initiation of IA alteplase or mechanical endovascular reperfusion therapy (MER). The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language.
Question:What is the highest NIHSS score documented within 36 hours following IA alteplase or MER initiation?

Format:
Length:3
Type:Alphanumeric
Occurs:1
Allowable Values:


Score = 0-42
UTD = Unable to Determine
Notes for Abstraction:
  • The NIHSS score may be documented by the physician/APN/PA or nurse (RN).
  • Look for the highest NIHSS score documented in less than or equal to 36 hours following initiation of IA alteplase or MER therapy.
  • For purposes of this data element, score documentation between 0 and 42 is acceptable.
  • If only one NIHSS score is documented within the first 36 hours following initiation of IA alteplase or MER therapy and no other NIHSS score(s) are available for comparison, enter the value for that score.
  • If multiple scores are documented within the first 36 hours following initiation of IA alteplase or MER therapy, select the highest score.
    EXAMPLES:
    • IA alteplase initiated at 1247 with first deployment of a mechanical reperfusion device at 1303. NIHSS Score is 10 at 1500 and 20 at 2300. Select NIHSS score of 20.
    • IA alteplase infusion initiated on 9/5/20XX at 0900. NIHSS score is 8 on 9/5/20XX at 2300, 10 on 9/6/20XX at 0100, and 8 on 9/6/20XX at 0300. Select NIHSS score 10.
    • MER initiated on 9/5/20XX at 0900. NIHSS score 3 on 9/6/20XX at 0900, 2 on 9/8/20XX at 0900, and 6 on 9/10/2012 at 0900. Select 3.
  • If no NIHSS score is documented within 36 hours following IA alteplase or MER therapy initiation, select “UTD”.
  • If unable to determine the highest score documented within 36 hours following IA alteplase or MER therapy initiation, select “UTD”.
Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • History and physical
  • Nursing flow sheet
  • Progress notes
  • Admitting note
  • Nursing assessment
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None
  • Modified NIHSS scores
  • Estimated NIHSS scores
  • Scoring methodologies other than NIHSS

Highest NIHSS Score Documented Within 36 Hours Following IA Alteplase or MER Initiation
CPT® only copyright 2019 American Medical Association. All rights reserved.
Specifications Manual for Joint Commission National Quality Measures (v2020B)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)

CPT® only copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

You, your employees and agents are authorized to use CPT® only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. You acknowledge that the American Medical Association (“AMA”) holds all copyright, trademark and other rights in CPT®.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT® for resale and/or license, transferring copies of CPT® to any party not bound by this Agreement, creating any modified or derivative work of CPT®, or making any commercial use of CPT®. License to use CPT® for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt.

U.S. Government Rights This product includes CPT® which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The American Medical Association does not agree to license CPT® to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The American Medical Association reserves all rights to approve any license with any Federal agency.

Disclaimer of Warranties and Liabilities. CPT® is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the (AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “accept”.

^