Specifications Manual for Joint Commission National Quality Measures (v2026A)

Posted: 08/08/2025

Release Notes:
Release Notes
Version 2026A

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Release Notes for the TJC2026A Manual

Measure Information Forms

Section	Rationale	Description
ASR-IP-1	The measure rationale and references were updated to include 2025 stroke statistics from the American Heart Association.	Rationale Change from: The administration of IV alteplase to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial in several clinical trials (Class I, Level of Evidence A, American Heart Association/American Stroke Association (AHA/ASA), 2019). These included two positive randomized controlled trials in the United States: The National Institute of Neurological Disorders and Stroke (NINDS) Studies, Part I and Part II. Based on the results of these studies, the Food and Drug Administration (FDA) approved the use of intravenous alteplase for the treatment of acute ischemic stroke when given within 3 hours of stroke symptom onset. A large meta-analysis controlling for factors associated with stroke outcome confirmed the benefit of IV alteplase in patients treated within 3 hours of symptom onset. Physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment. The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous r-tPA (alteplase) can be given safely to, and can improve outcomes for, carefully selected patients treated 3 to 4.5 hours after stroke; however, as the NINDS investigators concluded, the earlier that IV thrombolytic therapy is initiated, the better the patient outcome. Therefore, the target for IV alteplase initiation remains within 3 hours of time last known well. The administration of IV alteplase beyond 3 hours of stroke symptom onset has not been FDA approved. Although the benefit of IV alteplase has been well established, only a minority of patients with acute ischemic stroke actually receive this medication across the United States, despite the removal of many previous contraindications and warnings for alteplase therapy in recent years. Updated recommendations from the AHA/ASA in 2019 identify tenecteplase as a reasonable alternative to alteplase in acute ischemic stroke patients with minor neurological impairment and no major intracranial occlusion (0.4-mg/kg single IV bolus), or who are also eligible to undergo mechanical thrombectomy (0.25 -mg/kg single IV bolus, maximum 25 mg). Clinical evidence at this time is unclear whether tenecteplase is as effective as or more effective than alteplase (Class IIb, Level of Evidence BR). The administration of IV tenecteplase for ischemic stroke within or beyond 3 hours of stroke symptom onset has not been FDA approved. To: The administration of IV alteplase to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial in several clinical trials (Class I, Level of Evidence A, American Heart Association/American Stroke Association (AHA/ASA), 2019). These included two positive randomized controlled trials in the United States: The National Institute of Neurological Disorders and Stroke (NINDS) Studies, Part I and Part II. Based on the results of these studies, the Food and Drug Administration (FDA) approved the use of intravenous alteplase for the treatment of acute ischemic stroke when given within 3 hours of stroke symptom onset. A large meta-analysis controlling for factors associated with stroke outcome confirmed the benefit of IV alteplase in patients treated within 3 hours of symptom onset. Physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment. The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous r-tPA (alteplase) can be given safely to, and can improve outcomes for, carefully selected patients treated 3 to 4.5 hours after stroke; however, as the NINDS investigators concluded, the earlier that IV thrombolytic therapy is initiated, the better the patient outcome. Therefore, the target for IV alteplase initiation remains within 3 hours of time last known well. The administration of IV alteplase beyond 3 hours of stroke symptom onset has not been FDA approved. Although the benefit of IV alteplase has been well established, only a minority of patients with acute ischemic stroke actually receive this medication across the United States, despite the removal of many previous contraindications and warnings for alteplase therapy in recent years. Updated recommendations from the AHA/ASA in 2019 identified IV tenecteplase (TNK) as a reasonable alternative to alteplase. In March, 2025, IV TNK received FDA-approval for the treatment of acute ischemic stroke (AIS) in adults. The approval is based on a large multi-center non-inferiority study demonstrating that the efficacy of TNK and alteplase are comparable. Symptomatic intracranial hemorrhage (ICH) is a potential complication with both agents. However, a systematic review of 26 studies comparing IV TNK with alteplase suggests slightly less risk of an event (RR 0.89, 95% CI, 0.65-1.23) with TNK (Martin, 2025). Selected References Add: Martin, S.S., Aday, A.W., Allen, N.B., Almarzooq, Z.I., Anderson, C.A.M., Arora, P.,…Palaniappan, L.P. “2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association.” [In eng]. Circulation 151, (Feb 25 2025): e353. Remove: Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al. "Heart Disease and Stroke Statistics--2012 Update: A Report from the American Heart Association." [In eng]. Circulation 125, no. 1 (Jan 3 2012): e2-e220.
ASR-OP-1	The measure rationale and references were updated to include 2025 stroke statistics from the American Heart Association.	Rationale Change from: The administration of IV alteplase to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial in several clinical trials (Class I, Level of Evidence A, American Heart Association/American Stroke Association (AHA/ASA), 2019). These included two positive randomized controlled trials in the United States: The National Institute of Neurological Disorders and Stroke (NINDS) Studies, Part I and Part II. Based on the results of these studies, the Food and Drug Administration (FDA) approved the use of intravenous alteplase for the treatment of acute ischemic stroke when given within 3 hours of stroke symptom onset. A large meta-analysis controlling for factors associated with stroke outcome confirmed the benefit of IV alteplase in patients treated within 3 hours of symptom onset. Physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment. The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous r-tPA (alteplase) can be given safely to, and can improve outcomes for, carefully selected patients treated 3 to 4.5 hours after stroke; however, as the NINDS investigators concluded, the earlier that IV thrombolytic therapy is initiated, the better the patient outcome. Therefore, the target for IV alteplase initiation remains within 3 hours of time last known well. The administration of IV alteplase beyond 3 hours of stroke symptom onset has not been FDA approved. Although the benefit of IV alteplase has been well established, only a minority of patients with acute ischemic stroke actually receive this medication across the United States, despite the removal of many previous contraindications and warnings for alteplase therapy in recent years. Updated recommendations from the AHA/ASA in 2019 identify tenecteplase as a reasonable alternative to alteplase in acute ischemic stroke patients with minor neurological impairment and no major intracranial occlusion (0.4-mg/kg single IV bolus), or who are also eligible to undergo mechanical thrombectomy (0.25 -mg/kg single IV bolus, maximum 25 mg). Clinical evidence at this time is unclear whether tenecteplase is as effective as or more effective than alteplase (Class IIb, Level of Evidence BR). The administration of IV tenecteplase for ischemic stroke within or beyond 3 hours of stroke symptom onset has not been FDA approved. To: The administration of IV alteplase to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial in several clinical trials (Class I, Level of Evidence A, American Heart Association/American Stroke Association (AHA/ASA), 2019). These included two positive randomized controlled trials in the United States: The National Institute of Neurological Disorders and Stroke (NINDS) Studies, Part I and Part II. Based on the results of these studies, the Food and Drug Administration (FDA) approved the use of intravenous alteplase for the treatment of acute ischemic stroke when given within 3 hours of stroke symptom onset. A large meta-analysis controlling for factors associated with stroke outcome confirmed the benefit of IV alteplase in patients treated within 3 hours of symptom onset. Physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment. The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous r-tPA (alteplase) can be given safely to, and can improve outcomes for, carefully selected patients treated 3 to 4.5 hours after stroke; however, as the NINDS investigators concluded, the earlier that IV thrombolytic therapy is initiated, the better the patient outcome. Therefore, the target for IV alteplase initiation remains within 3 hours of time last known well. The administration of IV alteplase beyond 3 hours of stroke symptom onset has not been FDA approved. Although the benefit of IV alteplase has been well established, only a minority of patients with acute ischemic stroke actually receive this medication across the United States, despite the removal of many previous contraindications and warnings for alteplase therapy in recent years. Updated recommendations from the AHA/ASA in 2019 identified IV tenecteplase (TNK) as a reasonable alternative to alteplase. In March, 2025, IV TNK received FDA-approval for the treatment of acute ischemic stroke (AIS) in adults. The approval is based on a large multi-center non-inferiority study demonstrating that the efficacy of TNK and alteplase are comparable. Symptomatic intracranial hemorrhage (ICH) is a potential complication with both agents. However, a systematic review of 26 studies comparing IV TNK with alteplase suggests slightly less risk of an event (RR 0.89, 95% CI, 0.65-1.23) with TNK (Martin, 2025). Selected References Add: Martin, S.S., Aday, A.W., Allen, N.B., Almarzooq, Z.I., Anderson, C.A.M., Arora, P.,…Palaniappan, L.P. “2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association.” [In eng]. Circulation 151, (Feb 25 2025): e353. Remove: Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al. "Heart Disease and Stroke Statistics--2012 Update: A Report from the American Heart Association." [In eng]. Circulation 125, no. 1 (Jan 3 2012): e2-e220.
CSTK-02	The rationale for the measure and references were updated to address 2025 stroke statistics from the American Heart Association.	Rationale Change from: The Modified Rankin Scale (mRS) is the accepted standard for assessing recovery post-stroke. As such, it has become the most widely used clinical outcome measure for stroke clinical trials. Scores are used to measure the degree of disability or dependence in activities of daily living. Score reliability and reproducibility are improved through use of a structured interview by a trained evaluator. Interviews may be conducted in-person or over the phone. According to guideline recommendations from the American Heart Association/American Stroke Association, standardized interviews to obtain a mRS score should be conducted for acute ischemic stroke patients treated with IV or IA alteplase therapy or mechanical endovascular reperfusion therapy at 3 months (90 days); however, recovery may continue well beyond 3 months for many ischemic stroke patients. To: The Modified Rankin Scale (mRS) is the accepted standard for assessing recovery post-stroke. As such, it has become the most widely used clinical outcome measure for stroke clinical trials. Scores are used to measure the degree of disability or dependence in activities of daily living. Score reliability and reproducibility are improved through use of a structured interview by a trained evaluator. Interviews may be conducted in-person or over the phone. According to guideline recommendations from the American Heart Association/American Stroke Association, standardized interviews to obtain a mRS score should be conducted for acute ischemic stroke patients treated with IV or IA alteplase therapy or mechanical endovascular reperfusion therapy at 3 months (90 days); however, recovery may continue well beyond 3 months for many ischemic stroke patients. Recent clinical studies (e.g., AURORA, BEST, BASICS, BAOCHE, ATTENTION) have evaluated stroke disability at 90 days following endovascular therapy (EVT) for patients with large vessel occlusions. Patients undergoing EVT were more likely to achieve favorable outcomes and functional independence as assessed by mRS score of 0-2 when compared to medical management. Selected References Add: Martin, S.S., Aday, A.W., Allen, N.B., Almarzooq, Z.I., Anderson, C.A.M., Arora, P.,…Palaniappan, L.P. “2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association.” [In eng]. Circulation 151, (Feb 25 2025): e354. Special Notice Remove: *SUSPENDED for Thrombectomy-Capable Stroke Centers, Effective July 1, 2022*
CSTK-06	A misspelling of vasospasm was noted and updated to provide clarification.	Change from: Cerebral vasopasm is a serious complication following SAH, occurring in 30% to 70% of patients and accounting for nearly 50% of the deaths in patients surviving to treatment. To: Cerebral vasospasm is a serious complication following SAH, occurring in 30% to 70% of patients and accounting for nearly 50% of the deaths in patients surviving to treatment.
CSTK-10	The rationale for the measure and references were updated to address 2025 stroke statistics from the American Heart Association.	Rationale Change from: The Modified Rankin Scale (mRS) is the accepted standard for assessing recovery post-stroke. As such, it has become the most widely used clinical outcome measure for stroke clinical trials. Scores are used to measure the degree of disability or dependence in activities of daily living. Score reliability and reproducibility are improved through use of a structured interview by a trained evaluator. Interviews may be conducted in-person or over the phone. According to guideline recommendations from the American Heart Association/American Stroke Association, standardized interviews to obtain a mRS score should be conducted for acute ischemic stroke patients treated with IV or IA alteplase therapy or mechanical endovascular reperfusion therapy at 3 months (90 days); however, recovery may continue well beyond 3 months for many ischemic stroke patients. To: The Modified Rankin Scale (mRS) is the accepted standard for assessing recovery post-stroke. As such, it has become the most widely used clinical outcome measure for stroke clinical trials. Scores are used to measure the degree of disability or dependence in activities of daily living. Score reliability and reproducibility are improved through use of a structured interview by a trained evaluator. Interviews may be conducted in-person or over the phone. According to guideline recommendations from the American Heart Association/American Stroke Association, standardized interviews to obtain a mRS score should be conducted for acute ischemic stroke patients treated with IV or IA alteplase therapy or mechanical endovascular reperfusion therapy at 3 months (90 days); however, recovery may continue well beyond 3 months for many ischemic stroke patients. Recent clinical studies (e.g., AURORA, BEST, BASICS, BAOCHE, ATTENTION) have evaluated stroke disability at 90 days following endovascular therapy (EVT) for patients with large vessel occlusions. Patients undergoing EVT were more likely to achieve favorable outcomes and functional independence as assessed by mRS score of 0-2 when compared to medical management. Selected References Add: Martin, S.S., Aday, A.W., Allen, N.B., Almarzooq, Z.I., Anderson, C.A.M., Arora, P.,…Palaniappan, L.P. “2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association.” [In eng]. Circulation 151, (Feb 25 2025): e354.
HBIPS	Updates to the HBIPS IPP and Algorithm are to provide abstractor clarification and to align with the updated technical guidance provided in the data entry guide.	HBIPS Initial Patient Population Remove: The HBIPS measure set is unique in that there is one Initial Patient Population within the measure set, event measures (HBIPS-2 and HBIPS-3). Change from (right below strata table): Patients for which an event occurs (Event Date exists) while in a Psychiatric Care Setting (='Y') in the hospital are included in one of the Strata Initial Populations for the event measures. There is no sampling for the HBIPS event measures. All patients in the Initial Population for HBIPS event measures are automatically sampled. To: Patients for which an event occurs (Event Date exists) while in a Psychiatric Care Setting (='Y') in the hospital are included in one of the Strata Initial Patient Populations for the event measures. There is no sampling for the HBIPS event measures. The measures in HBIPS-EVT (HBIPS-2 and HBIPS-3) are not eligible for sampling and will use the entire Initial Patient Population for reporting. Add: (after the strata examples before algorithm and also in the note boxes 2 and 3 in the algorithm) NOTE: Initial Patient Population Size – Psychiatric Inpatient Days Medicare Only and Psychiatric Inpatient Days Non-Medicare Only for HBIPS Event measures are not derived from those cases that pass through the Initial Patient Population algorithm. Instead, these data are derived from the HBIPS census data calculated by (Psychiatric Inpatient Days – Total Leave Days). Please refer to the HBIPS-2 and HBIPS-3 data element calculation example in the data entry guide for technical guidance. The following Initial Patient Population algorithm is used to identify cases with events that occur in the psychiatric setting that will be used to run through algorithms HBIPS 2 and 3 to determine the numerator. Algorithm- note boxes 2 and 3 Change From: Note: Initial Patient Population Size – Medicare Only and Non-Medicare Only for HBIPS Event measures are not derived from those cases that pass through the Initial Patient Population algorithm. Instead, these data are derived from the HBIPS census data calculated by (Psychiatric Inpatient Days - Total Leave Days). To: Note: Initial Patient Population Size – Psychiatric Inpatient Days Medicare Only and Psychiatric Inpatient Days Non-Medicare Only for HBIPS Event measures are not derived from those cases that pass through the Initial Patient Population algorithm. Instead, these data are derived from the HBIPS census data calculated by (Psychiatric Inpatient Days – Total Leave Days). Please refer to the HBIPS-2 and HBIPS-3 data element calculation example in the data entry guide for technical guidance. Update in algorithm narrative note after step 5, same as updated in the algorithm flow.
HBIPS-2	Updates to the HBIPS Measure Information Forms, data elements, and Algorithm are to provide abstractor clarification and to align with the updated technical guidance provided in the data entry guide. The aggregated denominator box information from algorithm has been clarified in more detail and moved to the technical guidance in the data entry guide, located in Confluence.	Numerator Basis Add: * Please refer to the HBIPS-2 and HBIPS-3 data element calculation example in the data entry guide for technical guidance. Denominator Basis Add: * Please refer to the HBIPS-2 and HBIPS-3 data element calculation example in the data entry guide for technical guidance for aggregated denominator. Algorithm Remove: Algorithm Narrative for Measure calculation for Aggregated Denominator box.
HBIPS-3	Updates to the HBIPS Measure Information Forms, data elements, and Algorithm are to provide abstractor clarification and to align with the updated technical guidance provided in the data entry guide. The aggregated denominator box information from algorithm has been clarified in more detail and moved to the technical guidance in the data entry guide, located in Confluence.	Numerator Basis Add: * Please refer to the HBIPS-2 and HBIPS-3 data element calculation example in the data entry guide for technical guidance. Denominator Basis Add: * Please refer to the HBIPS-2 and HBIPS-3 data element calculation example in the data entry guide for technical guidance for aggregated denominator. Algorithm Remove: Algorithm Narrative for Measure calculation for Aggregated Denominator box.
IMM-2	The updates to IMM MIF include an updated rationale with more recent data, will provide abstractor clarification, alignment with updated CDC influenza vaccination guidance, and more up to date references.	Rationale Change from: Up to 1 in 5 people in the United States get influenza every season (CDC, Key Facts 2015). Each year an average of approximately 226,000 people in the US are hospitalized with complications from influenza and between 3,000 and 49,000 die from the disease and its complications (Thompson 2003). Combined with pneumonia, influenza is the nation’s 8th leading cause of death (Heron 2012). Up to two-thirds of all deaths attributable to pneumonia and influenza occur in the population of patients that have been hospitalized during flu season regardless of age (Fedson 2000). The Advisory Committee on Immunization Practices (ACIP) recommends seasonal influenza vaccination for all persons 6 months of age and older to highlight the importance of preventing influenza. Vaccination is associated with reductions in influenza among all age groups (Kostova 2013). The influenza vaccination is the most effective method for preventing influenza virus infection and its potentially severe complications. Screening and vaccination of inpatients is recommended, but hospitalization is an underutilized opportunity to provide vaccination to persons 6 months of age or older. To: An estimated 9.3 to 41 million people in the United States get influenza every season. Each year approximately 120,000 to 710,000 people in the US are hospitalized with complications from influenza and between 6,300 and 52,000 die from the disease and its complications (Center for Disease Control and Prevention [CDC], 2024a). Combined with pneumonia, influenza is in the nation’s top 10 leading causes of death for ages 1 through 44 (CDC, 2023). About 14.1% of people of all ages hospitalized with influenza were admitted to the intensive care unit during the 2021-22 flu season, down from 22.3% during the 2013-14 flu season (Naquin et al., 2024). The Advisory Committee on Immunization Practices (ACIP) recommends seasonal influenza vaccination for all persons 6 months of age and older to highlight the importance of preventing influenza. Flu vaccines substantially reduced the risk of flu related medical visits and hospitalizations for all age groups during the 2023-24 flu season (CDC, 2024b). The influenza vaccination is the most effective method for preventing influenza virus infection and its potentially severe complications. Screening and vaccination of inpatients is recommended, but hospitalization is an underutilized opportunity to provide vaccination to persons 6 months of age or older. Included Populations (Numerator) Change from: Patients who have an allergy/sensitivity to the influenza vaccine, anaphylactic latex allergy or anaphylactic allergy to eggs, or for whom the vaccine is not likely to be effective because of bone marrow transplant within the past 6 months, or history of Guillian-Barre syndrome within 6 weeks after a previous influenza vaccination, or symptomatic suspected or confirmed COVID-19. To: Patients who have documentation of a severe allergic reaction (e.g. anaphylaxis) after previous dose of influenza vaccine or to vaccine component, OR history of Guillian-Barré syndrome within 6 weeks after a previous influenza vaccination OR moderate or severe acute illness with or without fever. Selected References Change from: Centers for Disease Control and Prevention. (2013). Estimated Applications/LocalApps.Influenza Illnesses and Hospitalizations Averted by Influenza Vaccination — United States,2012–13 Influenza Season. MMWR. 2013;62(49):997-1000. To: Centers for Disease Control and Prevention. (2013). Estimated Influenza Illnesses and Hospitalizations Averted by Influenza Vaccination — United States,2012–13 Influenza Season. MMWR. 2013;62(49):997-1000. Remove: Centers for Disease Control and Prevention. (2015). Key facts about influenza and the influenza vaccine, October 2015. Available at:http://www.cdc.gov/flu/keyfacts.htm. Accessed October 14, 2015 Centers for Disease Control and Prevention. (2013). Estimated Influenza Illnesses and Hospitalizations Averted by Influenza Vaccination — United States,2012–13 Influenza Season. MMWR. 2013;62(49):997-1000. Centers for Disease Control and Prevention. (2013). Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States, 2013-2014. MMWR, September 20,2013; 62(RR07); 1-43. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6207a1.htm Centers for Disease Control and Prevention. (2015). Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States, 2015–16 Influenza Season. MMWR,August 7, 2015; 64(30);818-825. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a3.htm Fedson DS, Houck PM, Bratzler DW. Hospital-based influenza and pneumococcal vaccination: Sutton’s Law applied to prevention. Infect ControlHosp Epi. 2000;21:692-699. Heron M (2015). Deaths: Leading Causes for 2012. National Vital StatisticsReports; vol 64 no 10. Hyattsville, MD: National Center for Health Statistics.2015. Kostova D, Reed C, Finelli L, Cheng P, Gargiullo PM, Shay DK, Singleton JA,Meltzer MI, Lu P, Joseph S. (2013). Influenza Illness and HospitalizationsAverted by Influenza Vaccination in the United States, 2005–2011. PLoS One.2013; 8(6): e66312. Reed C, Chaves SS, Daily Kirley P, Emerson R, Aragon D, Hancock EB, et al.(2015). Estimating Influenza Disease Burden from Population-Based Surveillance Data in the United States. PLoS ONE 10(3): e0118369 Thompson WW, Shay DK, Weintraub E, Brammer L, Cox N, Anderson LJ,Fukuda. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA. 2003 January 8; 289 (2): 179-186. Add: Centers for Disease Control and Prevention. (2023). Leading causes of death. WISQARS. https://wisqars.cdc.gov/lcd/?o=LCD&y1=2023&y2=2023&ct=10&cc=ALL&g=00&s=0&r=0&ry=2&e=0&ar=lcd1age&at=groups&ag=lcd1age&a1=0&a2=199 Centers for Disease Control and Prevention. (2024a). Frequently asked questions about estimating influenza burden. https://www.cdc.gov/flu-burden/php/about/faq.html Centers for Disease Control and Prevention. (2024b). 2023-2024 flu vaccines reduce medical visits. https://www.cdc.gov/flu/whats-new/2023-2024-vaccines-reduce-medical-visits.html Centers for Disease Control and Prevention. (2024, July 25). General best practices for immunization. Vaccines & immunizations. https://www.cdc.gov/vaccines/hcp/imz-best-practices/?CDC_AAref_Val=https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html Centers for Disease Control and Prevention. (2024, July 25). Contraindications and precautions. Vaccines & immunizations. https://www.cdc.gov/vaccines/hcp/imz-best-practices/contraindications-precautions.html Naquin, A., O’Halloran, A., Ujamaa, D., et al. (2024). Laboratory-confirmed influenza-associated hospitalizations among children and adults — Influenza Hospitalization Surveillance Network, United States, 2010–2023. MMWR Surveillance Summaries, 73(SS-6), 1–18. http://dx.doi.org/10.15585/mmwr.ss7706a1 Rubin L, Levin M, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58(3):e44-100. DOI: 10.1093/cid/cit684
PC-02	Coding guidance FAQ link was added for clarification of coding for genital herpes.	Denominator Excluded Populations Add: to the end of the first bullet under FAQs for additional coding guidance https://datacenter.cmqcc.org/support/download/a7955e52541df8ed63aa8e884909d81caeb1f659
PC-06	Changes were made to the measure concerning transfers to another facility or other healthcare facility. Previously, all transfers to other facilities were severe complications. Transfers will now go through the algorithm to assess for severe complication codes or no codes, which will be severe complications, and moderate complication codes, which will now be moderate complications. This change will result in a new Algorithm and Narrative Algorithm also. Due to the extensive changes to the algorithm, for this manual publication only, the steps numbers are included, and changes are highlighted in green.	Description: Change: from: Unexpected complications among full term newborns with no preexisting conditions. Severe complications include neonatal death, transfer to another hospital for higher level of care, severe birth injuries such as intracranial hemorrhage or nerve injury, neurologic damage, severe respiratory and infectious complications such as sepsis. Moderate complications include diagnoses or procedures that raise concern but at a lower level than the list for severe e.g. use of CPAP or bone fracture. Examples include less severe respiratory complications e.g. Transient Tachypnea of the Newborn, or infections with a longer length of stay not including sepsis, infants who have a prolonged length of stay of over 5 days. To: Unexpected complications among full term newborns with no preexisting conditions. Severe complications include neonatal death, severe birth injuries such as intracranial hemorrhage or nerve injury, neurologic damage, severe respiratory and infectious complications such as sepsis. It also includes transfer to another hospital for higher level of care with severe complication codes or NO Moderate or Severe ICD-10-CM Principal Diagnosis Code, ICD-10-CM Other Diagnosis Codes, ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes. Moderate complications include diagnoses or procedures that raise concern but at a lower level than the list for severe e.g. use of CPAP or bone fracture. Examples include less severe respiratory complications e.g. Transient Tachypnea of the Newborn, or infections with a longer length of stay not including sepsis, infants who have a prolonged length of stay of over 5 days. Transfer to another hospital for higher level of care with any moderate complication codes are also included. Included Populations: Severe Complications: Change: Second bullet from: Transfer to another acute care facility for higher level of care To: Transfer to another acute care facility for higher level of care with severe complication codes or NO Moderate or Severe ICD-10-CM Principal Diagnosis Code, ICD-10-CM Other Diagnosis Codes, ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes regardless of length of stay. Moderate Complications: Add: First bullet Transfer to another hospital for higher level of care with any moderate complication codes regardless of length of stay. Algorithm Change Change: Step 4 Check Discharge Disposition Change the branch b and c to b. If Discharge Disposition equals 2, 3 or 6, the branch will go to step 23 to check Severe Complications. c. If Discharge Disposition equals 1, 4, 5, 7 or 8, the branch will go to step 5 to check ICD-10-CM Principal or Other Diagnosis Codes. Change: Step 8 Check ICD-10-CM Principal or Other Diagnosis Codes If at least one of the ICD-10-CM Principal or Other Diagnosis Codes is on Table 11.45 , the branch will go to step 9 to check Discharge Disposition. Add: New Check box for Discharge Disposition 9. Check Discharge Disposition If Discharge Disposition is 4 or 5, the branch will go to step 23 to check Severe Complications. If Discharge Disposition is 1, 7, or 8 the branch will go to step 10 to check Length of Stay. Change to: Step 12 Check ICD-10-PCS Principal or Other Procedure Codes.(BR> If at least one of the ICD-10-PCS Principal or Other Procedure Codes is on Table 11.48, the branch will go to step 27 to check Moderate Complications. If all ICD-10-PCS Principal or Other Procedure Codes are missing or none of them on Table 11.48, the branch will go to step 13 to check Discharge Disposition. Add: New Check box for Discharge Disposition 13. Check Discharge Disposition If Discharge Disposition is 4 or 5, the branch will go to step 17 to check ICD-10-CM Principal or Other Diagnosis Codes If Discharge Disposition is 1, 7, or 8, the branch will go to step 14 to check ICD-10-CM Principal or Other Diagnosis Codes Change to: Step 18 Check ICD-10-PCS Principal or Other Procedure Codes If at least one of the ICD-10-PCS Principal or Other Procedure Codes is on Table 11.51, or 11.52 , the branch will go to step 27 to check Moderate Complications. If all ICD-10-PCS Principal or Other Procedure Codes are missing or none of them on Table 11.51, 11.52, the branch will go to step 19 to check Discharge Disposition. Add: New Check box for Discharge Disposition 19. Check Discharge Disposition. If Discharge Disposition is 4 or 5, the branch will go to step 23 to check Severe Complications. If Discharge Disposition is 1, 7, or 8, the branch will go to step 20 to check Length of Stay. Narrative Change Step 4b,4c from: 4b. If Discharge Disposition equals 3, 4, 5 or 6, the case will proceed to Step 20 to check Severe Complications. 4c. If Discharge Disposition equals 1, 2, 7 or 8, continue processing and proceed to check ICD-10-CM Principal or Other Diagnosis Codes. To 4b. If Discharge Disposition equals 2, 3 or 6, the case will proceed to Step 23 to check Severe Complications. 4c. If Discharge Disposition equals 1, 4, 5, 7 or 8, continue processing and proceed to check ICD-10-CM Principal or Other Diagnosis Codes. Change Step 8a from: 8. Check ICD-10-CM Principal or Other Diagnosis Codes a. If at least one of the ICD-10-CM Principal or Other Diagnosis Codes is on Table 11.45, the case will proceed to check Length of Stay. To: 8. Check ICD-10-CM Principal or Other Diagnosis Codes a. If at least one of the ICD-10-CM Principal or Other Diagnosis Codes is on Table 11.45, the case will proceed to step 9 to check Discharge Disposition. Add: Step 9: 9. Check Discharge Disposition a. If Discharge Disposition is 4 or 5 proceed to step 23 to check Severe Complications. b. If Discharge Disposition is 1, 7, or 8 proceed to step 10 to Check to check Length of Stay. Change all step number after step 9. Change: Step 11 from: 11. Check ICD-10-PCS Principal or Other Procedure Codes a. If at least one of the ICD-10-PCS Principal or Other Procedure Codes is on Table 11.48, the case will proceed to Step 24 to check Moderate Complications. b. If all ICD-10-PCS Principal or Other Procedure Codes are missing or none of them on Table 11.48, continue processing and proceed to check ICD-10-CM Principal or Other Diagnosis Codes. To: 12. Check ICD-10-PCS Principal or Other Procedure Codes a. If at least one of the ICD-10-PCS Principal or Other Procedure Codes is on Table 11.48, the case will proceed to Step 27 to check Moderate Complications. b. If all ICD-10-PCS Principal or Other Procedure Codes are missing or none of them on Table 11.48, continue processing and proceed to step 13 to check Discharge Disposition. Add: Step 13: 13. Check Discharge Disposition a. If Discharge Disposition is 4 or 5 proceed to step 17 to check ICD-10-CM Principal or Other Diagnosis Codes. b. If Discharge Disposition is 1, 7, or 8 proceed to step 14 to check ICD-10-CM Principal or Other Diagnosis Codes. Change all step number after step 13. Change: Step 16 from: 16. Check ICD-10-PCS Principal or Other Procedure Codes If at least one of the ICD-10-PCS Principal or Other Procedure Codes is on Table 11.51, or 11.52 , the case will proceed to step 24 to check Moderate Complications. b. If all ICD-10-PCS Principal or Other Procedure Codes are missing or none of them on Table 11.51, 11.52, continue processing and proceed to step 17 to check Length of Stay. To: 18. Check ICD-10-PCS Principal or Other Procedure Codes If at least one of the ICD-10-PCS Principal or Other Procedure Codes is on Table 11.51, or 11.52 , the case will proceed to step 27 to check Moderate Complications. b. If all ICD-10-PCS Principal or Other Procedure Codes are missing or none of them on Table 11.51, 11.52, continue processing and proceed to step 19 to check Discharge Disposition. Add: Step 19: 19. Check Discharge Disposition a. If Discharge Disposition is 4 or 5 proceed to step 23 to check Severe Complications. b. If Discharge Disposition is 1, 7, or 8 proceed to step 20 to check Length of Stay. Change all step number after step 19.
STK-3	The rationale for the measure and references were updated to address 2025 stroke statistics from the American Heart Association.	Rationale Change from: Nonvalvular atrial fibrillation (NVAF) is a common arrhythmia and an important risk factor for stroke. It is one of several conditions and lifestyle factors that have been identified as risk factors for stroke. It has been estimated that over 2 million adults in the United States have NVAF. While the median age of patients with atrial fibrillation is 75 years, the incidence increases with advancing age. For example, The Framingham Heart Study noted a dramatic increase in stroke risk associated with atrial fibrillation with advancing age, from 1.5% for those 50 to 59 years of age to 23.5% for those 80 to 89 years of age. Furthermore, a prior stroke or transient ischemic attack (TIA) are among a limited number of predictors of high stroke risk within the population of patients with atrial fibrillation. Therefore, much emphasis has been placed on identifying methods for preventing recurrent ischemic stroke as well as preventing first stroke. Prevention strategies focus on the modifiable risk factors such as hypertension, smoking, and atrial fibrillation. Analysis of five placebo-controlled clinical trials investigating the efficacy of warfarin in the primary prevention of thromboembolic stroke, found the relative risk of thromboembolic stroke was reduced by 68% for atrial fibrillation patients treated with warfarin. In recent years, novel oral anticoagulant agents (NOACs) have been developed and approved by the U.S. Food and Drug Administration (FDA) for stroke prevention, and may be considered as an alternative to warfarin for select patients. The administration of anticoagulation therapy, unless there are contraindications, is an established effective strategy in preventing recurrent stroke in high stroke risk-atrial fibrillation patients with TIA or prior stroke. To: Atrial fibrillation (AF) is a common arrhythmia and an important risk factor for stroke. It is one of several conditions and lifestyle factors that have been identified as risk factors for stroke. It has been estimated that 6.6 million individuals in the United States have AF, and the prevalence is expected to increase to 12.1 million by 2030. While the median age of patients with atrial fibrillation is 75 years, the incidence increases with advancing age (14.2 per 1000 PY at 65–69 years of age to 50.8 per 1000 PY at ≥85 years of age). Furthermore, a prior stroke or transient ischemic attack (TIA) are among a limited number of predictors of high stroke risk within the population of patients with atrial fibrillation. Nonparoxysmal AF compared to paroxysmal AF has been associated with a higher risk of stroke in this patient population. Therefore, much emphasis has been placed on identifying methods for preventing recurrent ischemic stroke as well as preventing first stroke. Prevention strategies focus on the modifiable risk factors such as hypertension, smoking, and atrial fibrillation. Anticoagulation therapy is recommended for secondary stroke prevention for ischemic stroke patients with AF, unless contraindicated. Globally, the use of direct oral anticoagulant medications has continued to increase since 2018 and the prevalence of vitamin K antagonist use decreased. However, about 10% of patients are still treated with antiplatelet medications only. Selected References Add: Martin, S.S., Aday, A.W., Allen, N.B., Almarzooq, Z.I., Anderson, C.A.M., Arora, P.,…Palaniappan, L.P. “2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association.” [In eng]. Circulation 151, (Feb 25 2025): e333-e334. Remove: Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al. "Heart Disease and Stroke Statistics--2012 Update: A Report from the American Heart Association." [In eng]. Circulation 125, no. 1 (Jan 3 2012): e2-e220.
STK-4	The measure rationale and references were updated to include 2025 stroke statistics from the American Heart Association.	Rationale Change from: The administration of IV alteplase to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial in several clinical trials (Class I, Level of Evidence A, American Heart Association/American Stroke Association (AHA/ASA), 2019). These included two positive randomized controlled trials in the United States: The National Institute of Neurological Disorders and Stroke (NINDS) Studies, Part I and Part II. Based on the results of these studies, the Food and Drug Administration (FDA) approved the use of intravenous alteplase for the treatment of acute ischemic stroke when given within 3 hours of stroke symptom onset. A large meta-analysis controlling for factors associated with stroke outcome confirmed the benefit of IV alteplase in patients treated within 3 hours of symptom onset. Physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment. The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous r-tPA (alteplase) can be given safely to, and can improve outcomes for, carefully selected patients treated 3 to 4.5 hours after stroke; however, as the NINDS investigators concluded, the earlier that IV thrombolytic therapy is initiated, the better the patient outcome. Therefore, the target for IV alteplase initiation remains within 3 hours of time last known well. The administration of IV alteplase beyond 3 hours of stroke symptom onset has not been FDA approved. Although the benefit of IV alteplase has been well established, only a minority of patients with acute ischemic stroke actually receive this medication across the United States, despite the removal of many previous contraindications and warnings for alteplase therapy in recent years. Updated recommendations from the AHA/ASA in 2019 identify tenecteplase as a reasonable alternative to alteplase in acute ischemic stroke patients with minor neurological impairment and no major intracranial occlusion (0.4-mg/kg single IV bolus), or who are also eligible to undergo mechanical thrombectomy (0.25 -mg/kg single IV bolus, maximum 25 mg). Clinical evidence at this time is unclear whether tenecteplase is as effective as or more effective than alteplase (Class IIb, Level of Evidence BR). The administration of IV tenecteplase for ischemic stroke within or beyond 3 hours of stroke symptom onset has not been FDA approved. To: The administration of IV alteplase to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial in several clinical trials (Class I, Level of Evidence A, American Heart Association/American Stroke Association (AHA/ASA), 2019). These included two positive randomized controlled trials in the United States: The National Institute of Neurological Disorders and Stroke (NINDS) Studies, Part I and Part II. Based on the results of these studies, the Food and Drug Administration (FDA) approved the use of intravenous alteplase for the treatment of acute ischemic stroke when given within 3 hours of stroke symptom onset. A large meta-analysis controlling for factors associated with stroke outcome confirmed the benefit of IV alteplase in patients treated within 3 hours of symptom onset. Physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment. The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous r-tPA (alteplase) can be given safely to, and can improve outcomes for, carefully selected patients treated 3 to 4.5 hours after stroke; however, as the NINDS investigators concluded, the earlier that IV thrombolytic therapy is initiated, the better the patient outcome. Therefore, the target for IV alteplase initiation remains within 3 hours of time last known well. The administration of IV alteplase beyond 3 hours of stroke symptom onset has not been FDA approved. Although the benefit of IV alteplase has been well established, only a minority of patients with acute ischemic stroke actually receive this medication across the United States, despite the removal of many previous contraindications and warnings for alteplase therapy in recent years. Updated recommendations from the AHA/ASA in 2019 identified IV tenecteplase (TNK) as a reasonable alternative to alteplase. In March, 2025, IV TNK received FDA-approval for the treatment of acute ischemic stroke (AIS) in adults. The approval is based on a large multi-center non-inferiority study demonstrating that the efficacy of TNK and alteplase are comparable. Symptomatic intracranial hemorrhage (ICH) is a potential complication with both agents. However, a systematic review of 26 studies comparing IV TNK with alteplase suggests slightly less risk of an event (RR 0.89, 95% CI, 0.65-1.23) with TNK (Martin, 2025). Selected References Add: Martin, S.S., Aday, A.W., Allen, N.B., Almarzooq, Z.I., Anderson, C.A.M., Arora, P.,…Palaniappan, L.P. “2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association.” [In eng]. Circulation 151, (Feb 25 2025): e353. Remove: Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al. "Heart Disease and Stroke Statistics--2012 Update: A Report from the American Heart Association." [In eng]. Circulation 125, no. 1 (Jan 3 2012): e2-e220.
STK-6	The rationale for the measure and references were updated to include 2025 stroke statistics from the American Heart Association.	Rationale Add a fifth sentence to the end of the paragraph: Patients with a history of prior stroke or TIA and LDL-C <70 mg/dL have a lower risk of another stroke or cardiovascular event without increased risk for ICH compared to those patients with LDL-C 90-110 mg/dL (Martin, 2025). Selected References Add: Martin, S.S., Aday, A.W., Allen, N.B., Almarzooq, Z.I., Anderson, C.A.M., Arora, P.,…Palaniappan, L.P. “2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association.” [In eng]. Circulation 151, (Feb 25 2025): e334. Remove: Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al. "Heart Disease and Stroke Statistics--2012 Update: A Report from the American Heart Association." [In eng]. Circulation 125, no. 1 (Jan 3 2012): e2-e220.
THKR-IP	Removing statement for patient who is hospitalized overnight to improve understanding of Initial Patient Population.	THKR-IP Initial Patient Population Change from: The THKR measure set is unique in that there are two distinct strata within the measure set, each identified by a specific group of principal procedure codes, or lack thereof. The patients in each stratum are counted in the Initial Patient Population of multiple measures. The inpatient population is defined as a patient who is hospitalized overnight. To: The THKR measure set is unique in that there are two distinct strata within the measure set, each identified by a specific group of principal procedure codes, or lack thereof. The patients in each stratum are counted in the Initial Patient Population of multiple measures.
THKR-IP-1	Updated to include the Reason for No Regional Anesthesia data element.	Denominator - Excluded Populations (last bullet) Change from: Documented contraindication by physician/APN/PA (e.g. anticoagulated patients, coagulopathies, neurologic condition, previous spinal fusion) clearly indicated as reason for no regional anesthesia Change to: Patients with a documented Reason for No Regional Anesthesia
THKR-IP-2	Updated Table 14.10 name to be more inclusive of additional fracture codes added.	Excluded Populations Change from: Table 14.10 (femur, hip, pelvic fracture) To: Table 14.10 (Fractures)
THKR-IP-3	Updated Table 14.10 name to be more inclusive of additional fracture codes added.	Excluded Populations Change from: Table 14.10 (femur, hip, pelvic fracture) To: Table 14.10 (Fractures)
THKR-IP-4	Updated Table 14.10 name to be more inclusive of additional fracture codes added.	Excluded Populations Change from: Table 14.10 (femur, hip, pelvic fracture) To: Table 14.10 (Fractures)
THKR-IP-5	Updated Denominator Excluded Populations and added Pre-Collection Mortality data element to exclude patients who expire after the principal procedure and prior to the end of the data collection period. Updated Table 14.10 name to be more inclusive of additional fracture codes added.	Denominator: Excluded Populations Change from: Table 14.10 (femur, hip, pelvic fracture) To: Table 14.10 (Fractures) (last bullet) Add: Documentation that the patient expired after the principal procedure and prior to the end of the data collection period Data Elements (last bullet) Add: Pre-Collection Mortality Algorithm: Add: New check box for Pre-Collection Mortality after 2nd check box for ICD-10-CM Principal or Other Diagnosis Codes. If Pre-Collection Mortality is missing, the branch will go to Measure Category Assignment of X. If Pre-Collection Mortality equals Y, the branch will go to Measure Category Assignment of B. If Pre-Collection Mortality equals N, the branch will go to Check ICD-10-PCS Principal Procedure Date. Narrative: Change: Step 2a, 2b From: a. If ICD-10-CM Principal or Other Diagnosis Codes is At least one on Table 14.10, the case will proceed to a Measure Category Assignment of B and will be Not In Measure Population. For Overall Rate (THKR-IP-5a). Proceed to Step 8. b. If ICD-10-CM Principal or Other Diagnosis Codes is None on Table 14.10, the case will continue processing and proceed to Check ICD-10-PCS Principal Procedure Date. To: a. If ICD-10-CM Principal or Other Diagnosis Codes is At least one on Table 14.10, the case will proceed to a Measure Category Assignment of B and will be Not In Measure Population. For Overall Rate (THKR-IP-5a). Proceed to Step 9. b. If ICD-10-CM Principal or Other Diagnosis Codes is None on Table 14.10, the case will continue processing and proceed to Check Pre-Collection Mortality. Add: Step 3: 3. Check Pre-Collection Mortality a. If Pre-Collection Mortality is missing, the case will proceed to a Measure Category Assignment of X and Case Will Be Rejected. For Overall Rate (THKR-IP-5a). Proceed to Step 9. b. If Pre-Collection Mortality equals Y, the case will proceed to a Measure Category Assignment of B and will be Not In Measure Population. For Overall Rate (THKR-IP-5a). Proceed to Step 9. c. If Pre-Collection Mortality equals N, the case will continue processing and proceed to Check ICD-10-PCS Principal Procedure Date. Change all step numbers after step 3.
THKR-OP-1	Updated to include the Reason for No Regional Anesthesia data element.	Denominator - Excluded Populations (last bullet) Change from: Documented contraindication by physician/APN/PA (e.g. anticoagulated patients, coagulopathies, neurologic condition, previous spinal fusion) clearly indicated as reason for no regional anesthesia To: Patients with a documented Reason for No Regional Anesthesia
THKR-OP-2	Updated Table 14.10 name to be more inclusive of additional fracture codes added.	Excluded Populations Change from: Table 14.10 (femur, hip, pelvic fracture) To: Table 14.10 (Fractures)
THKR-OP-3	Updated Table 14.10 name to be more inclusive of additional fracture codes added.	Excluded Populations Change from: Table 14.10 (femur, hip, pelvic fracture) To: Table 14.10 (Fractures)
THKR-OP-4	Updated Table 14.10 name to be more inclusive of additional fracture codes added.	Excluded Populations Change from: Table 14.10 (Femur, hip, pelvic fracture) To: Table 14.10 (Fractures)
THKR-OP-5	Updated Denominator Excluded Populations and added Pre-Collection Mortality data element to exclude patients who expire after the principal procedure and prior to the end of the data collection period. Updated Table 14.10 name to be more inclusive of additional fracture codes added.	Denominator: Excluded Populations Change from: Table 14.10 (Femur, hip, pelvic fracture) To: Table 14.10 (Fractures) (last bullet) Add: Documentation that the patient expired after the principal procedure and prior to the end of the data collection period Data Elements (last bullet) Add: Pre-Collection Mortality Algorithm: Add: New check box for Pre-Collection Mortality after 2nd check box for ICD-10-CM Principal or Other Diagnosis Codes. If Pre-Collection Mortality is missing, the branch will go to Measure Category Assignment of X. If Pre-Collection Mortality equals Y, the branch will go to Measure Category Assignment of B. If Pre-Collection Mortality equals N, the branch will go to Check CPT Code Procedure Date. Narrative: Change: Step 2a, 2b from: a. If ICD-10-CM Principal or Other Diagnosis Codes is At least one on Table 14.10, the case will proceed to a Measure Category Assignment of B and will be Not In Measure Population. For Overall Rate (THKR-OP-5a). Proceed to Step 8. b. If ICD-10-CM Principal or Other Diagnosis Codes is None on Table 14.10, the case will continue processing and proceed to Check CPT Code Procedure Date. To: a. If ICD-10-CM Principal or Other Diagnosis Codes is At least one on Table 14.10, the case will proceed to a Measure Category Assignment of B and will be Not In Measure Population. For Overall Rate (THKR-OP-5a). Proceed to Step 9. b. If ICD-10-CM Principal or Other Diagnosis Codes is None on Table 14.10, the case will continue processing and proceed to Check Pre-Collection Mortality. Add: Step 3: 3. Check Pre-Collection Mortality a. If Pre-Collection Mortality is missing, the case will proceed to a Measure Category Assignment of X and Case Will Be Rejected. For Overall Rate (THKR-OP-5a). Proceed to Step 9. b. If Pre-Collection Mortality equals Y, the case will proceed to a Measure Category Assignment of B and will be Not In Measure Population. For Overall Rate (THKR-OP-5a). Proceed to Step 9. c. If Pre-Collection Mortality equals N, the case will continue processing and proceed to Check CPT Code Procedure Date. Change all step number after step 3.

Data Elements

Section	Rationale	Description
Discharge Date	The removal of the sentence referencing HBIPS is no longer applicable due to the retirement of HBIPS-1 and HBIPS-5. This data element is not collected for HBIPS-2 and HBIPS-3 since they are event measures.	Remove: For HBIPS only, if the patient was in an acute-care hospital and had multiple admissions to the psychiatric unit during his or her hospitalization, this information should be abstracted only once at the time of discharge from the hospital.
IA Alteplase or MER Initiation Time	The data element definition was updated to add an alternative inclusion term similar to procedure start time.	Inclusion Guidelines for Abstraction Add: Case start time
IA Route of Alteplase Administration	The U.S. Food and Drug Administration (FDA) approved intravenous (I.V.) tenecteplase for the treatment of acute ischemic stroke in adults on March 3, 2025.	Inclusion Guidelines for Abstraction Remove: Only Acceptable Thrombolytic Therapy for Stroke: Exclusion Guidelines for Abstraction Add: Intravenous (IV) tenecteplase Intra-arterial (IA) tenecteplase
Influenza Vaccination Status	The updates to IMM data element Influenza Vaccination Status will provide abstractor clarification and alignment with updated CDC influenza vaccination guidance.	Allowable Values Change from: 4 There was documentation of an allergy/sensitivity to influenza vaccine, anaphylactic latex allergy or anaphylactic allergy to eggs OR is not likely to be effective because of bone marrow transplant within the past 6 months OR history of Guillian-Barré syndrome within 6 weeks after a previous influenza vaccination OR symptomatic suspected or confirmed COVID-19. to: 4 Patients who have documentation of a severe allergic reaction (e.g. anaphylaxis) after previous dose of influenza vaccine or to vaccine component, OR history of Guillian-Barré syndrome within 6 weeks after a previous influenza vaccination OR moderate or severe acute illness with or without fever. Notes for Abstraction Add: Documentation of moderate or severe acute illness with or without fever must be in the current medical record with explicit linkage as the reason for not administering the influenza vaccine during this hospital stay. For inactivated influenza vaccine, conditions incorrectly perceived as contraindications or precautions (i.e., vaccines may be given under these conditions) to vaccination include: Non-severe (e.g., contact) allergy to latex, thimerosal, or egg Concurrent administration of Coumadin (generic: Warfarin) or aminophylline. For live attenuated influenza vaccine, conditions incorrectly perceived as contraindications or precautions (I.e., vaccines may be given under these conditions) to vaccination include: Health-care providers that see patients with chronic diseases or altered immunocompetence (an exception is providers for severely immunocompromised patients requiring care in a protected environment) Breastfeeding Contacts of persons with chronic disease or altered immunocompetence (an exception is contacts of severely immunocompromised patients requiring care in a protected environment). Guidelines for Abstraction (Inclusion) Change from: All patients discharged during October, November, December, January, February, or March Acceptable terms for influenza vaccines include those listed below or refer to the CDC Table: Influenza Vaccines- United States link for a list of Influenza vaccines at https://www.cdc.gov/flu/hcp/acip/. Afluria Flu shot Flu vaccine FluMist FluLaval Fluarix Fluvirin Fluzone Fluzone High Dose Influenza virus vaccine Live attenuated influenza vaccine Quadrivalent influenza vaccine Trivalent influenza vaccine to: All patients discharged during October, November, December, January, February, or March Acceptable terms for influenza vaccines include, but are not limited to, those listed below or refer to the CDC Table: Influenza Vaccines- United States link for a list of Influenza vaccines at https://www.cdc.gov/flu/hcp/acip/. Afluria Flu shot Flu vaccine FluMist FluLaval Fluarix Fluvirin Fluzone Fluzone High Dose Inactivated influenza vaccine Influenza virus vaccine Live attenuated influenza vaccine Quadrivalent influenza vaccine Trivalent influenza vaccine
IV Alteplase Initiation	The U.S. Food and Drug Administration (FDA) approved intravenous (I.V.) tenecteplase for the treatment of acute ischemic stroke in adults on March 3, 2025.	Inclusion Guidelines for Abstraction Change from: Only FDA-Approved Thrombolytic Therapy for Stroke: Activase Alteplase IV t-PA Recombinant t-PA Tissue plasminogen activator t-PA Tissue plasminogen activator Reasonable Alternative to Alteplase: Tenecteplase TNK TNKase To: Activase Alteplase IV t-PA Recombinant t-PA Tissue plasminogen activator Tenecteplase TNK TNKase t-PA Tissue plasminogen activator
IV Alteplase Prior to IA or Mechanical Reperfusion Therapy	The U.S. Food and Drug Administration (FDA) approved intravenous (I.V.) tenecteplase for the treatment of acute ischemic stroke in adults on March 3, 2025.	Inclusion Guidelines for Abstraction Change from: Only FDA-Approved Thrombolytic Therapy for Stroke: Activase Alteplase IV t-PA Recombinant t-PA Tissue plasminogen activator t-PA Tissue plasminogen activator Reasonable Alternative to Alteplase: Tenecteplase TNK TNKase To: Activase Alteplase IV t-PA Recombinant t-PA Tissue plasminogen activator Tenecteplase TNK TNKase t-PA Tissue plasminogen activator
IV OR IA Alteplase Administered at This Hospital or Within 24 Hours Prior to Arrival	The U.S. Food and Drug Administration (FDA) approved intravenous (I.V.) tenecteplase for the treatment of acute ischemic stroke in adults on March 3, 2025.	Inclusion Guidelines for Abstraction Change from: Only FDA-Approved Thrombolytic Therapy for Stroke: Activase Alteplase IV t-PA Recombinant t-PA Tissue plasminogen activator t-PA Tissue plasminogen activator Reasonable Alternative to Alteplase: Tenecteplase TNK TNKase To: Activase Alteplase IV t-PA Recombinant t-PA Tissue plasminogen activator Tenecteplase TNK TNKase t-PA Tissue plasminogen activator
Non-aneurysmal	Radiology reports and brain imaging reports were added as data sources as recommended by GWTG.	Suggested Data Sources Add: Brain imaging reports Radiology reports
Pre-Collection Mortality	Added new data element to exclude patients who expire after the principal procedure and prior to the end of the data collection period.	N/A
Psychiatric Inpatient Days - Medicare Only	Added clarification to the notes for abstraction for Psychiatric Inpatient Days Medicare Only and Non-Medicare Only data elements. This will align with the definition in the data entry guide that provides technical guidance.	Change from: For the purposes of calculating inpatient days, the admission day (Admission Date) but not the discharge day (Discharge Date) should be counted. The only exception will be for patients who are admitted and discharged on the same day. Such patients will contribute one inpatient day to the calculation. To: For the purposes of calculating inpatient days, the admission day (Admission Date) but not the discharge day (Discharge Date) should be counted. The only exception will be for patients who are admitted and discharged on the same day. Such patients will contribute one inpatient day to the calculation. In addition, patients admitted later in the day still contribute one inpatient day to the calculation.
Psychiatric Inpatient Days-Non-Medicare Only	Added clarification to the notes for abstraction for Psychiatric Inpatient Days Medicare Only and Non-Medicare Only data elements. This will align with the definition in the data entry guide that provides technical guidance.	Change from: For the purposes of calculating inpatient days, the admission day (Admission Date) but not the discharge day (Discharge Date) should be counted. The only exception will be for patients who are admitted and discharged on the same day. Such patients will contribute one inpatient day to the calculation. To: For the purposes of calculating inpatient days, the admission day (Admission Date) but not the discharge day (Discharge Date) should be counted. The only exception will be for patients who are admitted and discharged on the same day. Such patients will contribute one inpatient day to the calculation. In addition, patients admitted later in the day still contribute one inpatient day to the calculation.
Reason for Extending the Initiation of IV Alteplase	The U.S. Food and Drug Administration (FDA) approved intravenous (I.V.) tenecteplase for the treatment of acute ischemic stroke in adults on March 3, 2025.	Inclusion Guidelines for Abstraction Change from: Thrombolytic therapy t-PA To: Activase Alteplase IV t-PA Recombinant t-PA Tissue plasminogen activator Tenecteplase TNK TNKase t-PA Tissue plasminogen activator Exclusion Guidelines for Abstraction Change third bullet to: Hold IV alteplase or tenecteplase without a documented reason
Reason for No Regional Anesthesia	Updated data element definitions, allowable values, notes for abstraction, and guidelines for abstraction to provide abstractor clarification.	Question Change from: Is there physician/APN/PA documentation why regional anesthesia was not used or attempted for the procedure? To: Is there documentation as to justification for why regional anesthesia was not used or attempted for the procedure? Definition Change from: Reasons why regional anesthesia was not used or attempted for the procedure: Documentation of previous spinal fusion Documentation of patient/family refusal of regional anesthesia Other reasons why regional anesthesia was not used or attempted documented by physician/APN/PA To: Reasons why regional anesthesia was not used or attempted for the procedure: Documentation of previous spinal fusion Documentation of patient/family refusal of regional anesthesia Other reasons (e.g. anticoagulated patients, coagulopathies, neurologic condition) directly documented by a physician/APN/PA as to justification for why regional anesthesia was not used or attempted. Allowable Values Change from: Y (Yes) There is physician/APN/PA documentation why regional anesthesia was not used or attempted. N (No) There is no physician/APN/PA documentation why regional anesthesia was not used or attempted or unable to determine from medical record documentation. To: Y (Yes) There is documentation as to justification for why regional anesthesia was not used or attempted. N (No) There is no documentation as to justification for why regional anesthesia was not used or attempted or unable to determine from medical record documentation. Notes for Abstraction Change from: To select “Yes” for this data element, documentation of a reason for not using or attempting regional anesthesia must be dated prior to or on the PACU Discharge Date. If the patient did not go to the PACU, documentation must be dated prior to or on the day of surgery. If reasons are not mentioned in the context of anesthesia, do not make inferences (e.g., do not assume that regional anesthesia was not used because of a bleeding disorder unless documentation explicitly states so). Example: "Bleeding disorder”, review the chart for documentation about reason why regional anesthesia was not used or attempted. If no further documentation select “no”. “Recommend general anesthesia due to history of spinal fusion”, select “yes”. “Other” reasons for not using or attempting regional anesthesia must be documented by a physician/APN/PA. Exceptions to physician/APN/PA documentation of a reason for no regional anesthesia: Patient family refusal may be documented by a nurse, but must be dated prior to or on the PACU Discharge Date (or prior to or on the date of surgery if the patient did not go to the PACU). Patient/family refusal of any form of regional anesthesia is acceptable. Example: Patient refused spinal anesthesia, select “Yes.” Historical documentation present at the patient level in the electronic health record indicating the patient had a previous spinal fusion. As electronic data are available at all times during the encounter, it is acceptable to use this data for abstraction purposes. To: Selection of “Yes” for this data element: Documented history of spinal fusion present in the patient’s electronic health record is acceptable as a stand-alone reason for no regional anesthesia. Patient family refusal may be documented by physician/APN/PA OR a nurse, but must be dated prior to or on the PACU Discharge Date (or prior to or on the date of surgery if the patient did not go to the PACU). Patient/family refusal of any form of regional anesthesia is acceptable. Example: Patient refused spinal anesthesia, select “Yes.” Other reasons (e.g. anticoagulated patients, coagulopathies, neurologic condition) directly documented by a physician/APN/PA as justification for why regional anesthesia was not used or attempted. Documentation of a reason for not using or attempting regional anesthesia must be dated prior to or on the PACU Discharge Date. If the patient did not go to the PACU, documentation must be dated prior to or on the day of surgery. Example: “Recommend general anesthesia due to history of bleeding disorder”, documented by physician/APN/PA select “yes”. Selection of “No” for this data element: There is no documentation as to justification why regional anesthesia was not used or attempted, or if documentation is unclear. If “Other” reasons are not mentioned in the context of anesthesia, do not make inferences. Example: "Bleeding disorder”, review the chart for documentation about reason why regional anesthesia was not used or attempted. If no further documentation select “no” Guidelines for Abstraction - Inclusion Change from: Patient Refusal History of Spinal Fusion To: History of Spinal Fusion Patient Refusal Other reasons (e.g. anticoagulated patients, coagulopathies, neurologic condition) directly documented by a physician/APN/PA as justification for why regional anesthesia was not used or attempted.
Reason for Not Initiating IV Alteplase	The U.S. Food and Drug Administration (FDA) approved intravenous (I.V.) tenecteplase for the treatment of acute ischemic stroke in adults on March 3, 2025.	Inclusion Guidelines for Abstraction Change from: Thrombolytic therapy t-PA To: Activase Alteplase IV t-PA Recombinant t-PA Tissue plasminogen activator Tenecteplase TNK TNKase t-PA Tissue plasminogen activator Exclusion Guidelines for Abstraction Change third bullet to: Hold IV alteplase or tenecteplase without a documented reason
Regional Anesthesia	Updated definition to clarify intent of data element.	Definition Change from: Documentation that the procedure was performed using regional anesthesia or that regional anesthesia was attempted. Regional anesthesia includes neuraxial anesthesia (spinal and epidural blocks) as well as peripheral nerve blocks. Change to: Documentation that the procedure was performed using regional anesthesia or that regional anesthesia was attempted for the purpose of anesthesia during the operative episode. This does not include regional anesthesia used for the purpose of postoperative analgesia. Regional anesthesia includes neuraxial anesthesia (spinal and epidural blocks) as well as peripheral nerve blocks.

Supplemental Materials

Section	Rationale	Description
Appendix A - Code Tables	Multiple tables were updated to include the 2026 ICD-10 updates.	Table 10.01, 11.05,11.30,12.10, 14.02a, 8.2e were updated to align with the 2026 ICD-10 updates. The revisions include additions, deletions, and revisions to descriptions. Rationale: Multiple tables were updated to include the 2026 ICD-10 updates. Table 14.10 was updated to include an additional 3323 codes terminology. Rationale: Based on feedback and review with SME this update was to align with the CMS THA/TKA measure. Change Detail: Table 10.01 Name was updated to Mental Disorders-ED from Mental Disorders-HBIPS/ED. Rationale: Due to the removal of the HBIPS measures that utilized this table, the title was updated.
Appendix C - Medication Tables	Medication Tables 10.0 Antipsychotic Medications and 10.1 Short-acting Intramuscular Antipsychotic Medications tables have been transferred to the IPF Manual effective Jan 1, 2026. Medication Tables 9.1 FDA-Approved Tobacco Cessation Medications and 9.2 FDA-Approved Medications for Alcohol and Drug Dependence were updated to remove discontinued medications	Remove: Medication Tables 10.0 Antipsychotic Medications and 10.1 Short-acting Intramuscular Antipsychotic Medications Remove: Medications from Table 9.1 FDA-Approved Tobacco Cessation Medications: Chantix Nicorelief gum Nicorelief lozenge Nicotine inhaler Nicotrol TD Zyban Remove: Medications from Table 9.2 FDA-Approved Medications for Alcohol and Drug Dependence: Antabuse Campral Revia Oral
Appendix D - Glossary of Terms	Updated measure-specific data elements to include current measure set example. Removed reference to retired measure SCIP-INF-1-3 in prophylactic antibiotic. Rearranged Process Measure and Sample Size definitions for proper alphabetical order. Updated broken reference link to American College of Obstetricians and Gynecologists.	Change from: measure-specific data elements Data elements used by one specific measure or several measures in one specific measure set, such as Infection Prior to Anesthesia in the SCIP measures. To: measure-specific data elements Data elements used by one specific measure or several measures in one specific measure set, such as Gestational Age in the PC measures. Change from: prophylactic antibiotic An antibiotic used to prevent, rather than treat or cure, disease. For the purposes of SCIP-Inf-1-3, antibiotics given to prevent postoperative infection will be collected. Because the overuse of antibiotics can lead to resistance, antibiotics taken to prevent infection should be used only for a short time. To: prophylactic antibiotic An antibiotic used to prevent, rather than treat or cure, disease. Because the overuse of antibiotics can lead to resistance, antibiotics taken to prevent infection should be used only for a short time. Change from: American College of Obstetricians and Gynecologists (2014) Obstetric Data Definitions. Available at: http://www.acog.org/About-ACOG/ACOG-Departments/Patient-Safety-and-Quality-Improvement/reVITALize-Obstetric-Data-Definitions. To: American College of Obstetricians and Gynecologists (2014) Obstetric Data Definitions. Available at: https://www.acog.org/practice-management/health-it-and-clinical-informatics/revitalize-obstetrics-data-definitions
Appendix G - Resources	Updated broken link for CMQCC FAQ document.	Change from: There is also information on the FAQ provided by CMQCC on page 5-6. The link to the FAQ is: https://www.cmqcc.org/sites/default/files/Unexpected_Newborn_Complications_FAQs_2018 Datav2.pdf To: There is also information on the FAQ provided by CMQCC on page 5-6. The link to the FAQ is: https://www.cmqcc.org/files/Unexpected_Newborn_Complications_FAQs_2018 Datav2.pdf
Introduction to the Manual	Removed statement related to CMS Compare websites as it is no longer applicable for the Accelerate PI™ Performance Report.	Accelerate PI™ Performance Report Remove: In addition, the report uses a select subset of the most recent and available external data from the US Centers for Medicare & Medicaid Services (CMS) Compare websites that meet Joint Commission unique criteria for impact and actionability.
Using the The Joint Commission's National Measure Specifications Manual	The Joint Commission launched a new website and the location of the ORYX Performance Measure Reporting Requirements changed.	Change from: Measurement tab To: Performance Measurement page

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Specifications Manual for Joint Commission National Quality Measures (v2026A)
Discharges 01-01-26 (1Q26) through 06-30-26 (2Q26)

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