Performance Measurement Network

List of All Questions in the FAQ Database

Clinical Specification Questions

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

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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