Performance Measurement Network

List of All Questions in the FAQ Database

Clinical Specification Questions

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

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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