Performance Measurement Network

List of All Questions in the FAQ Database

Clinical Specification Questions

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