Performance Measurement Network

List of All Questions in the FAQ Database

Clinical Specification Questions

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