Performance Measurement Network

List of All Questions in the FAQ Database

Clinical Specification Questions

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

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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