Performance Measurement Network

Question: Earliest Reperfusion Procedure Date/Time for transferred patients

This question is in regards to the notes for abstraction bullet point for Earliest Reperfusion Procedure Date/Time. It states:

For ischemic stroke patients who receive intravenous (IV) alteplase(t-PA) at your hospital’s satellite/free-standing ED prior to transfer to the hospital and there is one medical record for the care provided at both facilities, use the arrival time at the hospital for the ICD-10-PCS Principal Procedure Time.

Does this specification also include hospitals that share a license and also have one medical records for the care provided for both facilities? For example, patient went to the ED in hospital A and received TPA, transferred to hospital B (same license, one medical record) for admission. Will the arrival time at hospital B used for the TPA time?


Kemi, The bullet was added specifically for PSCs that have a FSED and bill ED care with the inpatient admission. If IV alteplase is given at the FSED and billed with the inpatient admission, then the code for thrombolytic agent will require a NIHSS score documented before IV tPA, regardless if the NIHSS was repeated within 12 hrs at the PSC.

For cases that receive IV alteplase at another hospital and are transferred to a TSC/CSC for MER/ET reperfusion therapy, the score prior to the first reperfusion procedure done at the hospital should be used for abstraction.

Hope this clarifies for you. Thank you for your inquiry.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: CSTK-01,
Manual: Current Manual (current data collection period; prior to data transmission)

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