Performance Measurement Network

List of All Questions in the FAQ Database

Clinical Specification Questions

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

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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