Thank you for your inquiry regarding CMS996v4, Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). For the first question, our understanding is that your inquiry aims to confirm whether patients that are transferred to another facility’s ED are included in the measure denominator for the hospital that accepts the transfer. Both facilities, the one that transfers the patient with a STEMI diagnosis and the facility that accepts a STEMI patient into the ED would receive a score. This measure captures the percentage of ED encounters for patients 18 years and older with a diagnosis of STEMI who received appropriate treatment, defined as fibrinolytic therapy within 30 minutes of ED arrival, PCI 90 minutes of ED arrival, or transfer to Acute Care Facility within 45 minutes of ED arrival. As such, this case would be included in the measure’s denominator for both respective facilities, assuming none of the measure exclusion criteria apply. For the second question, your question intends to determine if cases in which patients received fibrinolytic therapy before ED arrival are excluded from the measure calculation. In CMS996v4 they are not excluded, however, the most recent version of the measure specifications (CMS996v5) introduced a denominator exception for ED encounters where the patient received fibrinolytic therapy at another facility within 24 hours. This refinement is applied from the CY2025 reporting period onward.