Performance Measurement Network

List of All Questions in the FAQ Database

Clinical Specification Questions

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

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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---++ Statistical Questions
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