Performance Measurement Network

List of All Questions in the FAQ Database

Clinical Specification Questions

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

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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