Performance Measurement Network

List of All Questions in the FAQ Database

Clinical Specification Questions

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

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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