Performance Measurement Network

List of All Questions in the FAQ Database

Clinical Specification Questions

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

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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