Performance Measurement Network

List of All Questions in the FAQ Database

Clinical Specification Questions

Question Related to
Continuing Care Plan-Discharge Medications Indications for Use HBIPS
STK-5 Antithrombotic - LOVENOX SQ STK
Pneumonia diagnosis: ED/Direct Admint PN
Comparative Data for Stroke Measures STK
Initial Blood Pressure at Hospital Arrival Field Format CSTK-03
Reason for No VTE Prophylaxis - Hemorrhagic Stroke Patient STK-01
Statin prescibed the day after discharge STK-06, STK-08
Discharge Medications and Indication for Use HBIPS-6, HBIPS-7
Is heparin 5000U SQ acceptable for antithrombitic administered by end day 2 STK
Last Known Well STK-04
Does CSTK - 03 include directly admitted transfers (that bypass ED?) CSTK-03
Is admission day counted as day 1 for STK-1? STK
Time Last Known Well STK
Expired after discharge CSTK-02
Can a patient undergoing Cardiac Surgery who received RBC's, FFP and Platelets be counted for more than one measure? BM
thyroid CA PC-01
Last Known Well Y/N? STK-4
Jan 2012 Follow-up monitoring VTE-05
HBIPS- Restraint and Seclusion in ED HBIPS-3
Can documentation on a pre-printed stroke order form for VTE Prophylaixs be used as a sufficient reason for no prophylaxis? STK-01
TEDS for VTE Prophylaxis STK, STK-01
Admitted for elective carotid intervention STK
what if Pradaxa (dabigatran is prescribed at discharge?) STK-02
Reason for Extending the Initiation of IV Thrombolytic STK, STK-04
What terms can be used for Comfort Measures Only? STK
Stroke Module STK
Do we need to collect 90 day mRS on pts undergoing CEA/CAS? CSTK
Can an addendum be added to the medical record? STK-01
Number of cases needed for submission BM
How should Last Known Well be abastracted when there is conflicting documentation in the medical record? STK-04
If a physician writes an order for SCDs, is this sufficient to select 'Yes' for VTE Prophylaxis? STK-01, VTE-01
Is Xarelto (Rivaroxaban an acceptable anticoagulant for STK-3?) STK-03
HBIPS-1 Timeframe for Screening Questions HBIPS
Antithrombotic Administration after t-PA STK-05
Assessed for Rehabilitation STK
Exclusive breast milk feeding definition PC
What are the recommendations for VTE prophylaxis for stroke patients? STK-01
Documentation ofJustification for Multiple Antipsychotic Medications HBIPS
Time Last Known Well - Conflicting Physician Documentation STK-04
IV Alteplase STK-OP
When there is a discharge summary and an addendum present in the medical record, which should be used? STK
Non Aneurysmal SAH Documentation CSTK-06
Last Known Well Version 5.2 STK-4
Multiple TICI reperfusion grades CSTK-08
Discharge Instructions for Activation of Emergency Medical System (EMS (911)) STK-08
Stroke Diagnosed Mid-Hospital Stay STK-5
Importance of exclusive breast milk feeding PC
Positive over negative findings STK-OP
Abstraction for Last Known Well STK-04
NIHSS Timed After Discharge CSTK-01
AMA and Number of Antipsychotic Meds Prescribed at Discharge HBIPS-4, HBIPS-5
Why is a Reason for No VTE Prophylaxis needed with graduated compression stockings (GCS/TEDs?) STK, STK-01
activity charting ACHF
Will certified Primary Stroke Centers be required to report the stroke performance measures as core measures? STK
Is Xarelto an antithromotic for use in Stroke? Can it be used for antithrombotic med at discharge? STK, STK-02
Triglyceride >400mg/dL STK
Reason for Not Prescribing Anticoagulation Therapy at Discharge STK-03
CSTK 4 Denominator Population CSTK-04
OBS: remains in the ED or transfer to another unit not in the ED STK-OP
Earliest principal procedure time/first pass time CSTK
Time Last Known Well is after hospital arrival STK-04
In the Operating Room, is "Estimated Blood Loss" for PRBC'S considered transfusion criteria? BM-02
How should we abstract pharmacological VTE prophylaxis when the patient is NPO? STK
Failed Attempt at Thrombectomy CSTK-08, CSTK-11, CSTK-12
Can post discharge documentation of a statin prescription be used in abstraction? STK-06
Transfer in patients that are intubated CSTK-01
Earliest Reperfusion Procedure Date/Time for transferred patients CSTK-01
CSTK4 documentation time? CSTK-04
Version 4.4 - Time Last Known Well and Reason Extending IV Thrombolytic STK-04
Are patients who have ischemic stroke occured after hospital arrival included in CSTK-01 population CSTK-01
Are patients admitted for elective basilar stenting excluded from the stroke chart audits? STK
Pre-anemia screening BM
Denominator exclusion population ICD-9 CM diagnosis codes CSTK, CSTK-03
Why aren't more exclusions to elective delivery considered? PC
Multiple Procedure Times CSTK, CSTK-01
in 2016, will the vendors still be able to submit STK HCD for STK Certification for our hospitals? STK
Is this considered a stroke clinical trial patient? STK
Data Abstraction for "Last Known Well" STK
PRE-stroke Modified Rankin Indicator question for Cstroke reporting CSTK-02
Sampling Requirements for CSTK CSTK
Who should perform mRS? CSTK-02
Thrombolytic therapy administered at satellite ED prior to hospital arrival STK
PSC Certified Hospitals: Sampling Methodology to Use for CSTK 1 for 2019 STK
Is there benchmark data available for HBIPS Data? HBIPS, HBIPS-1, HBIPS-1b, HBIPS-1c, HBIPS-1d, HBIPS-1e
Documentation for Stroke Education HF-1
What constitutes a failed thrombectomy CSTK-11
If tPA is given at an outside hospital by our Critical Transport Team, should we take credit? STK, STK-04
Risk of Violence to Self HBIPS, HBIPS-1
Multiple EMRs HBIPS
What should we do when conflicting or multiple times of last known well are documented? STK-04
Please submit all outpatient questions to QnetQuest.org OP
Why are patients that receive t-PA in the ED and then transferred to another hospital excluded from STK-4? STK-04
Are the following examples acceptable Reasons for Not Prescribing Anticoagulation and Antithrombotic Therapy at Discahrge? STK, STK-02
SCIP Inf-9 Urinary catheter removed on Postoperative Day 1 (POD 1 or Postoperative Day 2 (POD 2) with day of surgery being day zero ) SCIP, SCIP Inf-9
Please submit all CMS mortality measure questions directly to QnetQuest.org MORT
Sampling when both STK and CSTK are collected by a HCO CSTK
STK-1: IV Heparin for VTE Prophylaxis STK, STK-01
Reason for No Anticoagulation Therapy Prescribed at Discharge STK-03
Why aren't there more newborn conditions listed for not exclusively feeding breast milk? PC-05
For Q1 2013 fVTE and Oral Factor Xa inhibitor in Stroke patients. STK-01
STK 10 Assessed for rehabilitation STK-10
Earliest Aneurysm Repair or Surgical Interv Procedure Time CSTK
Follow-up to UserQuestion102705 CSTK
mRS CSTK
Is refusal of all IV's a Reason for Not Initiating IV Throbolytic Therapy? STK-04
What is the purpose of the Missing Branch ('X' Category Assignment for VTE Prophylaxis Date?) STK-01
Are retired Stroke Core Measures still required for comprehensive stroke centers? STK
Please submit all Emergency Department measure questions directly to QnetQuest.org ED, ED-1, ED-2
History of low vertical incision documented BUT no documentation of classical incision. PC-01
Patient Ambulatory At End of Hospital Day 2 STK
Positive Brain Image CSTK
NIHSS time STK
What would I document as Last Known Well? STK, STK-4
Pre-transfusion platelet count allowable value BM-04b
Continuing Care Plan Document Questions HBIPS
Define who is considered a stroke team for STK 4. STK
Evidence of Atherosclerosis STK
Can we use E/M code 99211? ACHF
What is the Date and Time Last Known Well? STK-04
Written discharge instructions for warfarin therapy VTE-05
Transfer between the Psychiatric Unit and Acute Care Unit HBIPS
Elective carotid intervention documentation STK
Lovenox in reference to STK-2, STK-5, and STK-3 STK-2, STK-3, STK-5
Statins at Discharge STK-06
Can an addendum be made to a pt's chart that has been d/c - Physician did not place the hunt & hess. CSTK
Is it considered CMO if the palliative care consult was done and the patient refuses palliative care the next day? STK
Patients transferred after t-PA STK
Question regarding the new STK OP 1 Measure STK-OP
Questions about sampling? ACHF
Support System ACHF
Recommended ways to obtain mRS CSTK, CSTK-02
Unable to Calculate LDL Value Due to High Triglycerides STK-06
One Episode of Care and Thrombolytic Therapy Administration STK
Nimodipine within 24 hours for non-aneurysmal SAH CSTK, CSTK-06
Date Last Known Well STK
If the patient enters the ED as a potential or actual TIA or hemorrhagic stroke patient, are the ED physicians required to document why the patient did not have IV thrombolytics initiated? STK
Reason For Not Administering Antithrombotic By End of Hospital Day 2 STK
Must the patient refuse both pharmacological and mechanical VTE prophylaxis to count as a reason for no prophylaxis? STK-01
Why does a patient treated with another lipid-lowering agent and with LDL < 100 fail the statin measure? STK-06
First Pass of a Mechanical Reperfusion Device / First Pass Time CSTK, CSTK-05
Referral to Next Level of Care HBIPS
Patient Referral to Next Level of Care Provider HBIPS
Elective Carotid Intervention STK
Pradaxa (dabigatran prescribed at discharge) STK-02
Stroke VTE Prophylaxis STK-01
Graduated Compression Stocking (GCS) STK
SUB 2 SUB
For patients transfused in Operating Room, how do we respond if there is no "written" order for transfusion. BM-05
can we accept a Drs documentation that it is not a hemorragic transformation CSTK, CSTK-05
Is the ambulatory patient considered low risk for VTE? STK
Small vessel disease as Evidence of Atherosclerosis STK, STK-06
Documentation added to D/C summary after discharge STK-6
Reason for not prescribing antithrombotic therapy at hospital discharge STK
Next Level of Care Provider Same as Hospital Provider HBIPS
EF on admission 15%. Day of discahrge EF 50-55% per ECHO. Do we answer Y for LVSD<40 . ACHF
Procedure codes for HF outpatients ACHF
First NIHSS performed days after admission CSTK-01
Clairfy time to recanalization CSTK, CSTK-07
Footling breech code 652.81 as an exclusion for PC-02 PC-02a
Arrival time for transferred patients CSTK-07
Stroke Measures STK-7 and STK-9 STK
Rehabilitation Assessment STK
LDL Measured within first 48 hrs or 30 days prior to hospital arrival STK
Will the new AHA recommendation of expasion of the time window for treatment wiht tPA be included in TJC measures/STK4? Other
Follow-up to UserQuestionId03Vte101043 VTE-05
Will Evidence of Atherosclerosis remain a STK-6 data element? STK
Reason for extending IV tPA STK-4
Should 'Yes' or 'No' be selected for IV Thrombolytic Initiation? STK
NIHSS Score Clarification CSTK-01
Why has this indicator has changed to include the word "elective"? STK
Why are there not more contraindications to vaginal deliveries? PC
Will Evidence of Atherosclerosis remain a data element? STK-06
Will files be rejected if all procedure codes do not have a procedure time? CSTK, CSTK-01, CSTK-03
Documentation of Last Known well STK, STK-4
CSTK-01 Procedures and Timing 1 calculation CSTK-01
STK-6 Reason for Not Prescribing a Statin Medication at Discharge STK
Psychiatic Care Setting -Patient Inclusion HBIPS
Data abstraction for VTE Prophylaxis when administered prior to admission STK
Significance of baseline mRS in calculation of CSTK-10 CSTK-10
Hunt and Hess & ICH Score Documentation CSTK-03
Definition of validated and non-validated screening tool for substance use SUB-01
Transmission of Continuing Care Plan (CCP) HBIPS, HBIPS-7
Failed attempt at thrombectomy CSTK-08
Data Element Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD at Discharge has an incomplete sentence ACHF-01
When both SCDs and TEDS are applied on the same day , how are they abstracted? STK
First Radiographic Image, CSTK 07 STK
Reason for Not Administering Antithrombotic Therapy? STK
Documentation Compliance for IV t-PA STK, STK-04
Consideration of PRADAXA as anticoagulation therapy for patients with atrial fibrillation STK-03
CSTK Procedure Times CSTK
Which version of the specifications should be used for stroke data collection? STK
Reason for not giving Nimodipine within 24 hours CSTK
Proof that next level of care provider contact information was transmitted with the Transition of Care Record ACHF
Appropriate Justification for Multiple Antipsychotic Meds at DC - Rationale for Allowable Value 4 HBIPS
What dose of enoxaparin is acceptable for use as antithrombotic therapy. STK-2, STK-5
Stroke after admission-arrival to skin puncture CSTK -09 CSTK
Lovenox 40mg daily - Antithrombotic Therapy Administered by End of Hospital Day Two STK
ABstraction for Date Last Known Well STK
Late Coded Stroke STK-4 and STK-5 STK, STK-4
CSTK 3 CSTK, CSTK-03
Use of Sweet-Ease速 and PC-05 (Exclusive Breast Milk Feeding) PC-05
Can the following note be used as a Reason for Not Prescribing Anticoagulation Therapy? STK-03
Can estimated blood loss (EBL be used for the data element pre-transfusion hemoglobin/hematocrit.) BM-02
Abstraction for Clinical Trial (STK ) STK
Retirement of STK-7 Dysphagia Screen STK-07
NIHSS versus mNIHSS CSTK-05
SCIP questions related to the April 2010 manual SCIP
Patients with subsequent admissions to the psychiatric unit HBIPS-1, HBIPS-6, HBIPS-7
Clarification of CSTK-1 Measure Population Requirements CSTK-01
Documention of Stroke education at discharge, STK-08
Birth Weight suggested Sources PC-06
Stroke Education Documentation Examples STK-08
STK-10 Assessed for Rehabilitation Services STK-10
Functional Status at Discharge ACHF
How is Length of Stay (LOS calculated for STK-1?) STK-01
Patient Receiving Continuing Care Plan Only HBIPS-6, HBIPS-7
Sampling Methodology for Stroke STK
Assessed for Rehabaliitation Services STK-10
What version of the Joint Commision manuel will be used starting with January 1, 2010? STK-01, STK-02, STK-03, STK-04, STK-05, STK-06, STK-07, STK-08, STK-09, STK-10, VTE
DVT Prophylaxis and Ambulation STK, STK-01
What value should be selected when VTE prophylaxis is administered several days after admission? STK
How to abstact Last Known Well when there is too much information? STK
ICH score documentation CSTK-03b
Statin therapy for patients 75yrs and older STK
MER code for combined billing for two hospitals-TSC CSTK, CSTK-08
Arrival Time for STK, CSTK and STK-OP Measures STK
When mutiple ejection fractions (EF are documented in the medical record, which value should we use?) ACHF
Graduated Compression Stockings as VTE Prophylaxis for Stroke Patients (STK-1) VTE-01, STK-1
STK-6 "Evidence of Atherosclerosis" STK
Dabigatran (PRADAXA use in Stroke Patients) STK
Follow-up to UserQuestionId03Stk100984 STK-04
Reason for Not Prescribing Antithrombotic / Anticoagulation at Discharge STK-02
Stroke Measure Requirements STK
Admission Date STK-01
Is full medication reconciliation required by PSCs to meet the Medication Education measure component? STK-08
Reason for Not Initiating IV Thrombolytic-conflicting GWTG instructions STK-04
Time Last Know Well -Stroke STK
Does Appendix H, Table 2.2 exclude ambulatory stroke patients from the VTE prophylaxis? STK
Dietary Advice "consistent amount" of foods with Vitamin K rather than avoidance should be advised. VTE-05
Time NIHSS performed CSTK-01
Will Primary Stroke Certification continue? STK
Does the following documentation meet education regarding Risk factors for stroke? STK
Can I use VTE used during the Observation, given prior to hospital admission STK-1
Why is ICD-9-CM Principal Diagnosis Code 436 used for ischemic stroke? STK
Are patients that stroke while an inpatient included in the measure population? STK
Last known well when symptoms resolve then reoccur STK
Date/Time of First Pass for CSTK-7 CSTK
Last Known Well STK, STK-04
Primary Stroke Certification and Transition to Stroke Core Measures STK
SCIP- Neuraxial Anesthesia- Epidural for pain control placed post-op SCIP
Follow-up to UserQuestionId03Stk100628 STK
Arrival time Abstraction. CSTK-11
Initial Date/time of NIHSS teleneurologist CSTK, CSTK-01
What dosage of Lovenox is suffiecient to meet antithrombotic therapy administered by end of hospital day 2 STK-05
Stroke that occurs after admission CSTK
What are the benchmarks for the new Outpatient Stroke Core Measures? STK-OP
Referral to Next Level of Care Provider-Trasmittal Question HBIPS-6
Does the reason for not presciribing anticoagulation therapy have to be documented on the dau of discharge? STK-03
Data Element- Violence Risk to Self HBIPS
ICD-9-CM Code 433.10 STK
How to Answer Questions on Advanced Stroke Tab Intent to Perform MER CSTK-08
Continuing Care Plan - Reason for Hospitalization HBIPS
WIll the new medication Pradaxa be acceptable as an anticoagulant at discharge? STK, STK-03
Optimal Medication Management ACHF
COVID-19 CSTK
MER Attempted During this Encounter - Clot Dissolved CSTK-11
Is intensive dosing of statin required to meet STK-6? STK
CSTK 02, 05, and 06 Measures CSTK-01, CSTK-02, CSTK-05, CSTK-06
Does a hold on anticoagulation count as a valid reason for not prescribing at discharge? STK-03
Reason for no VTE Prophylaxis - Elevated INR STK, STK-01
Sampling Requirements for CSTK CSTK
doucumentation of ich and hunt hess CSTK-03
Hunt & Hess/ ICH score documentation required by tele neuro radiology prior to transfer STK
The latest update indicates a favorable mRS as 0 1 or 2 post stroke with pre mRS 3 4 or 5 CSTK
Discharge Code and Transfers of Patients STK-OP
Activity specifics ACHF
Patient Population CSTK
If the admitting diagnosis is not stroke, can the case be excluded from STK-4? STK-04
Need information about the required import file specifications BM
What is the Date and Time of Last Well Known? STK-04
Rationale for Code Stroke Form as the Priority Data Source STK-4
HBIPS Discharge Status HBIPS
Clarification of data elements needed CSTK-05b, CSTK-07
MER Eligibility CSTK
HBIPS Event Dates Prior to Admission HBIPS
Stroke core measure data for PSC hospitals STK
Comprehensive Stroke (CSTK Sub-Populations) CSTK
Documentation for Rehabilitation Assessment STK-10
STK-4 IV Thrombolytic Therapy STK
Discharged on Anticoagulation Therapy STK
Inter-rater Reliability and Chart Re-asbstraction STK
Time of the teleneurology NIHSS CSTK-01
What is the Admission Date? STK
How should we abstract thrombolytic administration in the 3 to 4.5 hr timeframe when a reason for not administering existed within 3 hrs? STK, STK-04
PSC CSTK 01 population CSTK, CSTK-01
Are MRI reports an acceptable data source for Evidence of Atherosclerosis? STK-06
Documentation for tPA exclusion STK, STK-04
Reason for No VTE Prophylaxis STK, STK-01
STK-6 Data Entry in CMIP for Q1 2010 STK
Procedures Performed During Hospitalization ACHF
Procedure Time Inclusion Terms CSTK-03
Why does a patient on another lipid-lowering medication qualify and fail statin prescribed at discharge? STK-06
Reason for Not Initiating IV Thrombolytic STK
Abstraction Tools ASR-OP-1
Appointment for Follow Up/ Release of Information HBIPS, HBIPS-7
Refusal of SCD's STK, STK-01
VTE Prophlyaxis - Abstracting of Allowable Values STK-01
Documentation of Stroke Education STK-08
Does all medical record documentation need to be dated and timed? STK
Code 433.10 and Transient Ischemic Attack STK
Mother's choice not to breast feed PC-05

Clinical Algorithm Questions

Data Quality Questions

Measure Verification Questions

Measure Verification Questions

Technical Questions

Performance Measurement System Vendor - General Questions

Statistical Questions

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---++ Data Quality Questions
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---++ Measure Verification Questions
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---++ Technical Questions
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---++ Statistical Questions
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