Thank you for your inquiry regarding CMS996v5: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). The ICD-10-CM code Z92.82: Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility is used as a direct reference code in the measure logic to define the measure’s denominator exception: emergency department encounters where the patient received fibrinolytic therapy at another facility within 24 hours. The eCQI Resource Center defines direct reference codes as specific codes referenced directly in the eCQM measure logic to describe a data element or one of its attributes. It is the intention of the measure logic to use the presence of only one code, Z92.82, to define this denominator exception. Therefore, is not included in one of the measure’s value sets in VSAC.