Performance Measurement Network

List of All Questions in the FAQ Database

Clinical Specification Questions

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

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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---++ Measure Verification Questions
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---++ Statistical Questions
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