Specifications Manual for Joint Commission National Quality Measures (v2020B2)
Posted: 9/2/2020
Home » Positive Brain Image

Release Notes:
Data Element
Version 2020B2

Name:Positive Brain Image
Collected For: CSTK-05
Definition:Documentation of a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage following IV or IA alteplase therapy, OR mechanical endovascular reperfusion therapy initiation. The major risk of reperfusion therapy is hemorrhage
Question:Was there a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage following IV or IA alteplase therapy, or mechanical endovascular reperfusion therapy initiation?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (YES) Parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage was detected on brain imaging following IV or IA alteplase therapy, or mechanical endovascular reperfusion therapy initiation.

N (No) Parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage was not detected on brain imaging following IV or IA alteplase therapy, or mechanical endovascular reperfusion therapy initiation, OR Unable to determine (UTD) from the medical record documentation.
Notes for Abstraction:

  • For purposes of this data element, do not use brain imaging reports for CT/MRI performed prior to IV or IA alteplase initiation, or mechanical endovascular reperfusion (MER) therapy. Abstract only brain imaging reports for tests done after these interventions to select ‘YES’.
  • Patients with a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage on brain imaging following IV or IA alteplase therapy, or mechanical endovascular reperfusion therapy initiation, are acceptable to select “Yes”.
    • A confirmed report is not necessary. Reports of preliminary findings within this timeframe may be used in abstraction.
    • If the report documents that “hemorrhage cannot be excluded”, “cannot R/O hemorrhage”, or “findings suggestive of hemorrhage”, select “Yes”.
  • When conflicting information is documented in the medical record, select ‘YES’.
  • Documentation that the hemorrhage is "old", select 'NO'. Do not infer that a hemorrhage is old unless explicitly documented.
  • See the inclusion list for acceptable examples of documentation of a positive finding. The list is not all inclusive.

Suggested Data Sources: ONLY acceptable data source:
  • Brain imaging reports
  • Diagnostic test reports
  • Radiology reports
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion

  • Bleed
  • Blood
  • Blood product(s)
  • Brain hemorrhage
  • Cerebral hemorrhage
  • ECASS criteria PH1 or PH2
  • Hemorrhage
  • Hemorrhagic conversion
  • Hemorrhagic expansion
  • Hemorrhagic transformation
  • Intracerebral hemorrhage (ICH)
  • Intracranial hemorrhage
  • Intraparenchymal hemorrhage
  • Intraventricular hemorrhage
  • Parenchymal hematoma
  • Parenchymal hemorrhage
  • Parenchymal intracerebral hemorrhage
  • Small (e.g., bleed, hemorrhage)
  • Subarachnoid hemorrhage (SAH)

  • ECASS criteria H1 or H2
  • Incidental
  • Micro
  • Petechial
  • Punctate
  • Trace

Positive Brain Image
CPT® only copyright 2019 American Medical Association. All rights reserved.
Specifications Manual for Joint Commission National Quality Measures (v2020B2)
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”.

^