Performance Measurement Network

Question: Multiple Procedure Times

If the patient has more than one procedure code on table 8.1a or 8.1b, which procedure time would we use for the algorithm? Based on the measure definition, I would think we would use the earliest. Also, if one date and/or time was UTD and the other was a non-UTD value, would we continue with the non-UTD value or go out to a category D?

Answer:

The procedure time is a specific data element for this measure set, and handled by the measure calculation: • Any interested procedure code (in requested table, such as 8.1a or 8.1b for CSTK-01; and 8.2d or 8.2e for CSTK-03), must have non-UTD date and time value in order to pass the measure. • If multiple interested procedure codes are present, for example, there are IV t-PA and IA t-PA and mechanical endovascular reperfusion therapy performed during an episode of care, ALL interested procedure codes must be associated with non-UTD date and time value in order to pass the measure. • If a procedure code isn’t used by the measure calculation, the procedure time does not impact the measure result.

When multiple non-UTD procedure times are available, use the earliest time.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: CSTK, CSTK-01,
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