Specifications Manual for Joint Commission National Quality Measures (v2025A)
Posted: 09/13/2024

Release Notes:
Data Element
Version 2025A

Name:Skin Puncture Time
Collected For: CSTK-09, CSTK-12
Definition:The time (military time) of skin puncture at this hospital to access the arterial site selected for endovascular treatment of a cerebral artery occlusion.
Question:What is the time of skin puncture at this hospital to access the arterial site selected for endovascular treatment of a cerebral artery occlusion?
Format:
Length:5 - HH-MM (with or without colon) or UTD
Type:Time
Occurs:1
Allowable Values:


HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to Determine

Time must be recorded in military time format. With the exception of Midnight and Noon:
  • If the time is in the a.m., conversion is not required
  • If the time is in the p.m., add 12 to the clock time hour

Examples:

Midnight = 00:00
Noon = 12:00
5:31 am = 05:31
5:31 pm = 17:31
11:59 am = 11:59
11:59 pm = 23:59

Note:
00:00 = midnight. If the time is documented as 00:00 11-24-20xx, review supporting documentation to determine if the Skin Puncture Date should remain 11-24-20xx or if it should be converted to 11-25-20xx.

When converting Midnight or 24:00 to 00:00, do not forget to change the Skin Puncture Date.
Example:
Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx
Notes for Abstraction:
  • For times that include “seconds”", remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00.
  • If the Skin Puncture Time is unable to be determined from medical record documentation, select “UTD”.
  • The medical record must be abstracted as documented (taken at “face value”). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select “UTD”.
    Examples:
    Documentation indicates the Skin Puncture Time was 3300. No other documentation in the medical record provides a valid time. Since the Skin Puncture Time is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD”.
  • Abstract the Skin Puncture Time documented for endovascular treatment of the occluded cerebral artery.”
    Examples:
    Arrival time 1400. A-line started in the emergency department at 1425. Entered interventional suite at 1600. Anesthesia start time 1607. Groin puncture at 1615. Select 1615.
  • If multiple skin puncture times are documented for the same endovascular procedure, then select the earliest time.
    • Disregard times associated with unsuccessful access of the artery.
      Example:
      Physician documents 4/20 0350 attempted groin puncture unsuccessful, followed by documentation on 4/20 0356 successful groin puncture. Select 0356.

Suggested Data Sources:
  • Consultation notes
  • Diagnostic test reports
  • Operative notes
  • Operative report
  • Procedure notes
  • Procedure report
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Carotid puncture time
  • Brachial puncture time
  • Femoral puncture time
  • Groin puncture time
  • Radial puncture time

None

Skin Puncture Time
CPT® only copyright 2024 American Medical Association. All rights reserved.
Specifications Manual for Joint Commission National Quality Measures (v2025A)
Discharges 01-01-25 (1Q25) through 06-30-25 (2Q25)

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