Performance Measurement Network

List of All Questions in the FAQ Database

Clinical Specification Questions

Question Related to
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
Mother's choice not to breast feed PC-05
Is heparin 5000U SQ acceptable for antithrombitic administered by end day 2 STK
Definition of validated and non-validated screening tool for substance use SUB-01
Can documentation on a pre-printed stroke order form for VTE Prophylaixs be used as a sufficient reason for no prophylaxis? STK-01
Is there benchmark data available for HBIPS Data? HBIPS, HBIPS-1, HBIPS-1b, HBIPS-1c, HBIPS-1d, HBIPS-1e
Discharge Code and Transfers of Patients STK-OP
Stroke Education Documentation Examples STK-08
Stroke core measure data for PSC hospitals STK
Will Primary Stroke Certification continue? STK
CSTK 02, 05, and 06 Measures CSTK-01, CSTK-02, CSTK-05, CSTK-06
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
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
In the Operating Room, is "Estimated Blood Loss" for PRBC'S considered transfusion criteria? BM-02
Does the reason for not presciribing anticoagulation therapy have to be documented on the dau of discharge? STK-03
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
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
what if Pradaxa (dabigatran is prescribed at discharge?) STK-02
Documentation Compliance for IV t-PA STK, STK-04
HBIPS-1 Timeframe for Screening Questions HBIPS
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
Recommended ways to obtain mRS CSTK, CSTK-02
Rehabilitation Assessment STK
HBIPS- Restraint and Seclusion in ED HBIPS-3
Can we use E/M code 99211? ACHF
Sampling Requirements for CSTK CSTK
Reason for not giving Nimodipine within 24 hours CSTK
Reason for No VTE Prophylaxis STK, STK-01
Covid Vaccine Audit HCSS
Reason for No VTE Prophylaxis - Hemorrhagic Stroke Patient STK-01
Why are there not more contraindications to vaginal deliveries? PC
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
CSTK-01 Procedures and Timing 1 calculation CSTK-01
PSC CSTK 01 population CSTK, CSTK-01
What constitutes a failed thrombectomy CSTK-11
Hunt & Hess/ ICH score documentation required by tele neuro radiology prior to transfer STK
Documentation added to D/C summary after discharge STK-6
Functional Status at Discharge ACHF
Reason for no VTE Prophylaxis - Elevated INR STK, STK-01
Is this considered a stroke clinical trial patient? STK
Should 'Yes' or 'No' be selected for IV Thrombolytic Initiation? STK
Unable to Calculate LDL Value Due to High Triglycerides STK-06
Are retired Stroke Core Measures still required for comprehensive stroke centers? STK
Time NIHSS performed CSTK-01
Why does a patient on another lipid-lowering medication qualify and fail statin prescribed at discharge? STK-06
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
First NIHSS performed days after admission CSTK-01
MER Attempted During this Encounter - Clot Dissolved CSTK-11
Must the patient refuse both pharmacological and mechanical VTE prophylaxis to count as a reason for no prophylaxis? STK-01
Please submit all Emergency Department measure questions directly to QnetQuest.org ED, ED-1, ED-2
NIHSS Timed After Discharge CSTK-01
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
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
Please submit all outpatient questions to QnetQuest.org OP
Follow-up to UserQuestionId03Vte101043 VTE-05
ICH score documentation CSTK-03b
Initial Date/time of NIHSS teleneurologist CSTK, CSTK-01
Does a hold on anticoagulation count as a valid reason for not prescribing at discharge? STK-03
Patients with subsequent admissions to the psychiatric unit HBIPS-1, HBIPS-6, HBIPS-7
ABstraction for Date Last Known Well STK
Last Known Well Y/N? STK-4
Documentation of Stroke Education STK-08
Who should perform mRS? CSTK-02
If the admitting diagnosis is not stroke, can the case be excluded from STK-4? STK-04
The latest update indicates a favorable mRS as 0 1 or 2 post stroke with pre mRS 3 4 or 5 CSTK
Last Known Well STK, STK-04
Retirement of STK-7 Dysphagia Screen STK-07
Data Abstraction for "Last Known Well" STK
Will Evidence of Atherosclerosis remain a data element? STK-06
STK-5 Antithrombotic - LOVENOX SQ STK
Discharged on Anticoagulation Therapy STK
STK 10 Assessed for rehabilitation STK-10
What is the Admission Date? STK
What are the benchmarks for the new Outpatient Stroke Core Measures? STK-OP
Procedure Time Inclusion Terms CSTK-03
doucumentation of ich and hunt hess CSTK-03
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
Last Known Well Version 5.2 STK-4
If tPA is given at an outside hospital by our Critical Transport Team, should we take credit? STK, STK-04
Appointment for Follow Up/ Release of Information HBIPS, HBIPS-7
Sampling Requirements for CSTK CSTK
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
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
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
Clarification of CSTK-1 Measure Population Requirements CSTK-01
Initial Blood Pressure at Hospital Arrival Field Format CSTK-03
Referral to Next Level of Care Provider-Trasmittal Question HBIPS-6
Abstraction Tools ASR-OP-1
Patient Ambulatory At End of Hospital Day 2 STK
Why aren't more exclusions to elective delivery considered? PC
SCIP questions related to the April 2010 manual SCIP
Sampling Methodology for Stroke STK
Please submit all CMS mortality measure questions directly to QnetQuest.org MORT
OBS: remains in the ED or transfer to another unit not in the ED STK-OP
What terms can be used for Comfort Measures Only? STK
COVID-19 CSTK
Reason for Extending the Initiation of IV Thrombolytic STK, STK-04
Earliest Reperfusion Procedure Date/Time for transferred patients CSTK-01
Hunt and Hess & ICH Score Documentation CSTK-03
HBIPS Discharge Status HBIPS
Written discharge instructions for warfarin therapy VTE-05
STK-10 Assessed for Rehabilitation Services STK-10
Assessed for Rehabaliitation Services STK-10
Arrival time for transferred patients CSTK-07
Stroke VTE Prophylaxis STK-01
Lovenox 40mg daily - Antithrombotic Therapy Administered by End of Hospital Day Two STK
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
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
Date/Time of First Pass for CSTK-7 CSTK
Primary Stroke Certification and Transition to Stroke Core Measures STK
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
Referral to Next Level of Care HBIPS
Abstraction for Clinical Trial (STK ) STK
Continuing Care Plan Document Questions HBIPS
When mutiple ejection fractions (EF are documented in the medical record, which value should we use?) ACHF
Admission Date STK-01
Evidence of Atherosclerosis 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
Can I use VTE used during the Observation, given prior to hospital admission STK-1
Version 4.4 - Time Last Known Well and Reason Extending IV Thrombolytic STK-04
Support System ACHF
How is Length of Stay (LOS calculated for STK-1?) STK-01
How do I determine my firm group? HCSS
Is it considered CMO if the palliative care consult was done and the patient refuses palliative care the next day? STK
Positive Brain Image CSTK
Patients transferred after t-PA STK
Follow-up to UserQuestionId03Stk100628 STK
Multiple Procedure Times CSTK, CSTK-01
How to Answer Questions on Advanced Stroke Tab Intent to Perform MER CSTK-08
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
Is intensive dosing of statin required to meet STK-6? STK
ICD-9-CM Code 433.10 STK
SUB 2 SUB
Rationale for Code Stroke Form as the Priority Data Source STK-4
Reason for No Anticoagulation Therapy Prescribed at Discharge STK-03
Will certified Primary Stroke Centers be required to report the stroke performance measures as core measures? STK
Dabigatran (PRADAXA use in Stroke Patients) STK
Reason for extending IV tPA STK-4
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
Can a patient undergoing Cardiac Surgery who received RBC's, FFP and Platelets be counted for more than one measure? BM
Why has this indicator has changed to include the word "elective"? STK
Comprehensive Stroke (CSTK Sub-Populations) CSTK
Time Last Known Well 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
STK-6 Reason for Not Prescribing a Statin Medication at Discharge STK
Can the following note be used as a Reason for Not Prescribing Anticoagulation Therapy? STK-03
What value should be selected when VTE prophylaxis is administered several days after admission? STK
Time Last Known Well is after hospital arrival STK-04
Positive over negative findings STK-OP
Stroke that occurs after admission CSTK
Stroke after admission-arrival to skin puncture CSTK -09 CSTK
NIHSS time STK
What should we do when conflicting or multiple times of last known well are documented? STK-04
Documentation for Stroke Education HF-1
Why is ICD-9-CM Principal Diagnosis Code 436 used for ischemic stroke? STK
What number should we enter for the denominator? HCSS-6
Multiple EMRs HBIPS
Time Last Know Well -Stroke STK
Code 433.10 and Transient Ischemic Attack STK
Denominator exclusion population ICD-9 CM diagnosis codes CSTK, CSTK-03
Transfer between the Psychiatric Unit and Acute Care Unit HBIPS
CSTK Procedure Times CSTK
Failed Attempt at Thrombectomy CSTK-08, CSTK-11, CSTK-12
Need information about the required import file specifications BM
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
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 dose of enoxaparin is acceptable for use as antithrombotic therapy. STK-2, STK-5
What is the Date and Time of Last Well Known? STK-04
Admitted for elective carotid intervention STK
Can an addendum be made to a pt's chart that has been d/c - Physician did not place the hunt & hess. CSTK
Thrombolytic therapy administered at satellite ED prior to hospital arrival STK
If a physician writes an order for SCDs, is this sufficient to select 'Yes' for VTE Prophylaxis? STK-01, VTE-01
Refusal of SCD's STK, STK-01
Expired after discharge CSTK-02
Next Level of Care Provider Same as Hospital Provider HBIPS
Are patients admitted for elective basilar stenting excluded from the stroke chart audits? STK
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
Psychiatic Care Setting -Patient Inclusion HBIPS
When both SCDs and TEDS are applied on the same day , how are they abstracted? STK
DVT Prophylaxis and Ambulation STK, STK-01
Data Element- Violence Risk to Self 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
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
Lovenox in reference to STK-2, STK-5, and STK-3 STK-2, STK-3, STK-5
Optimal Medication Management ACHF
Jan 2012 Follow-up monitoring VTE-05
Documentation for Rehabilitation Assessment STK-10
Importance of exclusive breast milk feeding PC
Antithrombotic Administration after t-PA STK-05
Discharge Medications and Indication for Use HBIPS-6, HBIPS-7
Reason for Not Initiating IV Thrombolytic STK
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
Late Coded Stroke STK-4 and STK-5 STK, STK-4
Birth Weight suggested Sources PC-06
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
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
activity charting ACHF
CSTK 4 Denominator Population CSTK-04
TEDS for VTE Prophylaxis STK, STK-01
mRS CSTK
What dosage of Lovenox is suffiecient to meet antithrombotic therapy administered by end of hospital day 2 STK-05
PRE-stroke Modified Rankin Indicator question for Cstroke reporting CSTK-02
Last Known Well STK-04
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
Dietary Advice "consistent amount" of foods with Vitamin K rather than avoidance should be advised. VTE-05
Comparative Data for Stroke Measures STK
STK-6 Data Entry in CMIP for Q1 2010 STK
Reason for Not Administering Antithrombotic Therapy? STK
Non Aneurysmal SAH Documentation CSTK-06
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
Earliest Aneurysm Repair or Surgical Interv Procedure Time CSTK
AMA and Number of Antipsychotic Meds Prescribed at Discharge HBIPS-4, HBIPS-5
Use of Sweet-Ease速 and PC-05 (Exclusive Breast Milk Feeding) PC-05
Documentation for tPA exclusion STK, STK-04
Reason for Not Prescribing Antithrombotic / Anticoagulation at Discharge STK-02
Will files be rejected if all procedure codes do not have a procedure time? CSTK, CSTK-01, CSTK-03
Pre-anemia screening BM
Small vessel disease as Evidence of Atherosclerosis STK, STK-06
First Pass of a Mechanical Reperfusion Device / First Pass Time CSTK, CSTK-05
Procedures Performed During Hospitalization ACHF
MER Eligibility CSTK
Stroke Measure Requirements STK
NIHSS versus mNIHSS CSTK-05
Is Xarelto (Rivaroxaban an acceptable anticoagulant for STK-3?) STK-03
Appropriate Justification for Multiple Antipsychotic Meds at DC - Rationale for Allowable Value 4 HBIPS
Exclusive breast milk feeding definition PC
Pneumonia diagnosis: ED/Direct Admint PN
Transfer in patients that are intubated CSTK-01
Elective carotid intervention documentation STK
Documentation ofJustification for Multiple Antipsychotic Medications HBIPS
Are patients that stroke while an inpatient included in the measure population? STK
Activity specifics ACHF
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
Graduated Compression Stocking (GCS) STK
Patient Population CSTK
Clairfy time to recanalization CSTK, CSTK-07
Triglyceride >400mg/dL STK
STK-6 "Evidence of Atherosclerosis" STK
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
Graduated Compression Stockings as VTE Prophylaxis for Stroke Patients (STK-1) VTE-01, STK-1
What would I document as Last Known Well? STK, STK-4
Numerator Statement HCSS
Will the new AHA recommendation of expasion of the time window for treatment wiht tPA be included in TJC measures/STK4? Other
Can an addendum be added to the medical record? STK-01
Follow-up to UserQuestion102705 CSTK
Will Evidence of Atherosclerosis remain a STK-6 data element? STK
HBIPS Event Dates Prior to Admission HBIPS
Is full medication reconciliation required by PSCs to meet the Medication Education measure component? STK-08
CSTK 3 CSTK, CSTK-03
Clarification of data elements needed CSTK-05b, CSTK-07
Inter-rater Reliability and Chart Re-asbstraction STK
Define who is considered a stroke team for STK 4. 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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