Measure #10 - Stroke and stroke rehabilitation: CT or MRI reports.
PERFORMANCE DESCRIPTION:
Percentage of final reports for CT or MRI studies of the brain performed within 24 hours of
arrival to the hospital for patients aged 18 years and older with the diagnosis of ischemic stroke
or TIA or intracranial hemorrhage that include documentation of the presence or absence of each
of the following: hemorrhage and mass lesion and acute infarction.
REPORTING DESCRIPTION:
This measure is to be reported each time a CT or MRI is performed in a hospital or outpatient
setting during the reporting period for patients with a diagnosis of ischemic stroke, TIA, or
intracranial hemorrhage.
DOCUMENTATION:
The radiologist must provide the following information on the final report in order for ARB to
properly identify and code the PQRI study (See attachment A):
 The age of the patient.
 The number of hours past from the time that the patient arrived at the hospital vs. the
exam.
 The reason for the exam including symptoms. (EX: R/O stroke. Headace and dizziness)
 In the impression or findings: The absence or presence of all three of the following:
hemorrhage, mass lesion, and acute infarction.
CODING:
 CPT II 3110F: Presence or absence of hemorrhage and mass lesion and acute infarction
documented in final CT or MRI report.
 CPT II 3111F: CT or MRI of the brain performed within 24 hours of arrival to the
hospital.
 CPT II 3112F: CT or MRI of the brain performed greater than 24 hours after arrival to
the hospital.
 Modifier 8P: Presence or absence of hemorrhage and mass lesion and acute infarction
was not documented in final CT or MRI report, reason not otherwise specified.
 CPT codes 0042T, 70450, 70460, 70470, 70551, 70552, or 70553 are used to identify the
CT or MRI exam.
 ICD-9 diagnosis codes 431, 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01,
434.11, 434.91, 435.0, 435.1, 435.2, 435.3, 435.8, or 435.9 are used to identify patients
with a diagnosis of ischemic stroke or TIA or intracranial hemorrhage.
Successful Reporting Scenarios
Stroke or Stroke Rehabilitation: CT or MRI Reports
A 70 year old male patient with stroke symptoms is sent to radiology
for a CT of the brain without contrast.
The patient was seen
within 24 hours of the
arrival to the hospital and
the radiologist reports the
absence of hemorrhage,
mass lesion, and acute
infarction in the final
report. (All 3 must be
present)
Code 70450, 3110F, and
3111F
The CT was
performed greater than
24 hours after arrival
to the hospital.
Code 70450 and
3112F
The patient is seen
within 24 hours of arrival
ant there is no
documentation on the
final report of acute
infarction, mass lesion,
and hemhorrage. (All 3
must be present)
Code 70450, 3110F-8P,
and 3111F