Specifications Manual for Joint Commission National Quality Measures (v2020B)
Posted: 2/5/2020
Home » Pre-Stroke Modified Rankin Score (mRS)

Release Notes:
Data Element
Version 2020B

Name:Pre-Stroke Modified Rankin Score (mRS)
Collected For: CSTK-10
Definition:The pre-stroke Modified Rankin Score (mRS) is a score used to assess the patient’s pre-stroke or baseline level of function. Scores reflect the patient’s ability to perform activities of daily living prior to the hospitalization for the acute ischemic stroke event.

MODIFIED RANKIN SCALE
Score Description
0 The patient had no residual symptoms.
1 The patient had no significant disability; able to carry out all activities.
2 The patient has slight disability; unable to carry out all pre-stroke activities but able to look after self without daily help.
3 The patient has moderate disability; requiring some external help but able to walk without the assistance of another individual.
4 The patient has moderately severe disability; unable to walk or attend to bodily functions without assistance of another individual.
5 The patient has severe disability; bedridden, incontinent, requires continuous care.

Question:What is the patient's pre-stroke Modified Rankin Score (mRS)?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

1  A pre-stroke mRS of 0, 1, or 2 was documented in the medical record, OR physician/APN/PA documentation that the patient was able to look after self without daily help prior to this acute stroke episode.

2  A pre-stroke mRS of 3, 4, or 5 was documented in the medical record, OR physician/APN/PA documentation that the patient could NOT look after self without daily help prior to this acute stroke episode.

3  A pre-stroke mRS was not documented, OR unable to determine (UTD) from the medical record documentation.

Notes for Abstraction:
  • A pre-stroke mRS value (i.e., 0, 1, 2, 3, 4, or 5) may be documented by the physician/APN/PA, nurse (RN), medical assistant, or any individual trained to perform the mRS.
  • If more than one pre-stroke mRS value is documented, select the highest value.
  • If a score range is documented, e.g. 2-3, select the higher value.
  • Pre-stroke mRS values may be documented any time during the hospital stay or within 30 days prior to hospital arrival.
    EXCEPTION:
    • A discharge mRS cannot be used as a baseline pre-stroke mRS score. Score documentation must clearly reflect the patient’s functional status prior to arrival at the hospital for management of the acute ischemic stroke event.
  • If an acutal pre-stroke mRS value is not documented in the medical record, physician/APN/PA documentation only may be used to document the patient’s pre-stroke functional status.
    EXAMPLES:
    • “Patient independent and living alone prior to stroke onset. No past history of TIA or stroke”, select allowable value “1”.
    • “Mrs X lives with her daughter and has some memory deficit requiring assistance with meals and dressing. Ambulates without help”, select allowable value “2”.
  • If there is conflicting documentation of baseline pre-stroke functional status in the medical record, select the highest score value.
  • If there is an actual pre-stroke mRS value documented in the medical record, then that score should be used for abstraction over other physician/APN/PA documentation.
  • If no pre-stroke mRS is documented or unable to determine, select allowable value “3”.

Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • History and physical
  • Progress notes
  • Discharge summary
  • Admission note
  • Outpatient record
Additional Notes: Excluded Data Sources: Any documentation dated/timed after discharge
Guidelines for Abstraction:
Inclusion Exclusion
None None

Pre-Stroke Modified Rankin Score (mRS)
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”.

^