Thank you for your inquiry regarding CMS996v4: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). In terms of timing of appropriate treatment following a STEMI diagnosis, the measure captures three potential numerators for ED encounters with a STEMI diagnosis: PCI procedure within 90 minutes of ED arrival, fibrinolytic therapy within 30 minutes of ED arrival, or discharge to PCI-capable acute care within 45 minutes of ED arrival. We recommend working with your EHR vendor to capture the time from ED arrival to PCI device deployment time to capture the first numerator criteria: PCI performed within 90 minutes of ED arrival. The measure does not currently use timing of EKGs or time to cardiac catheterization lab in its numerator definitions. This decision was based on clinical expert input and measure testing results indicating that EKG timing in EHR documentation was unreliable. CMS will continue to evaluate feedback and recommendations during the annual update cycle and update the measure as needed to align with clinical guidelines and workflow. In terms of inclusion of the encounter described in the inquiry in the measure denominator, this situation is complex and depends on how the timing of the encounter is documented in the EHR. We assume from the inquiry that the patient boarded in the ED after their initial EKG and that they were not discharged from their ED encounter even though there was a decision to admit to inpatient care. If it is documented in the EHR that the STEMI diagnosis occurred during the ED encounter, while the patient was boarding, this encounter would be captured in the measure denominator. However, if the EHR documentation shows that the patient was in fact discharged from the ED following their initial EKG, but they physically remained in an ED bed to receive inpatient care, and the STEMI presented during this inpatient encounter, this encounter would not be captured in the measure denominator. Although all STEMI diagnoses may be captured from an inpatient encounter, only those occurring during the ED encounter would be included in the denominator.