Performance Measurement Network

Question: Arrival Time for STK, CSTK and STK-OP Measures

1. The specifications for the data element "Arrival Time" showed it is collected for the following measures: ASR-IP-1, ASR-OP-1, ASR-OP-2, CSTK-01, CSTK-03, CSTK-05, CSTK-06, CSTK-07, CSTK-09, CSTK-11, STK-4, STK-OP-1

2. We only have PSCs and CSCs within our system, so we only collect STK, STK OP and CSC measure data.

3. We need clarification of the following bullet within the Notes for Abstraction for Arrival Time:

• "If the patient was transferred from your hospital's satellite/free-standing ED or from another hospital within your hospital's system (as an inpatient or ED patient, and there is one medical record for the care provided at both facilities, use the arrival time at the first facility. CSTK, STK, AND ASR MEASURES ONLY EXCEPTION: Use the arrival time at the comprehensive stroke center/primary stroke center/acute stroke ready hospital".


1. Are you saying that since the Exception applies only to the CSTK, STK and ASR measures, if pt is transferred from one of our hospital's satellite/free-standing EDs to our PSC (or CSC as we have both levels within our system) and there is only one record for the care provided at both facilities (which suggests both facilities have the same CCN and the encounters are billed as one claim) that we should abstract the time the pt arrived at the 2nd facility that is the PSC (or CSC) as Arrival Time?

2. Is it correct that the exception does not apply to STK OP measure since the Exception is listed for CSTK, STK, AND ASR MEASURES ONLY?

3. So does that mean that the ED visit does not fall into the STK OP measure population because it should be treated like a transfer within the same facility with an inpatient claim rather than a transfer to another acute care facility?)


Patricia, 1. The exception is there because Joint Commission DSC stroke certifications, e.g., PSC and CSC, are awarded to an individual hospital/site and not the healthcare system. The intent of the stroke measures is to evaluate performance at the individual certified entity.

2. The exception should also be used for STK-OP per the rationale above.

3. STK-OP intends to capture the timeliness of any stroke patient's transfer out from the PSC ED to another acute care facility, regardless if the transfer is to a CSC within the same hospital system and/or using one CCN.

CCN billing rule is for CMS billing purposes and is not meaningful to the Joint Commission measure rates reported for stroke certification. The notes for abstraction about CCN are a carry-over from CMS/TJC measure alignment so that CMS does not pay twice for care that should only receive one payment / one hospital reimbursement.

Thank you for your inquiries.

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

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