Thank you for your inquiry regarding CMS996v5, Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). Please see responses to each of the three questions below. 1. We presume TKK is referring to a type of fibrinolytic therapy. If the patient received fibrinolytic therapy at another facility within 24 hours prior to admission at the current facility, they would not be included in the measure due to the measure’s denominator exception. 2.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 within 90 minutes of ED arrival, or discharge to a PCI-capable acute care facility within 45 minutes of ED arrival. To be captured in the initial patient population, the patient must be 18 years or older and have a STEMI diagnosis during the ED encounter that ends during the measurement period. The QDM does not prescribe the source of diagnosis data in the EHR. Therefore, diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. Even if the patient did not arrive at the ED with a STEMI and instead developed the STEMI during the ED encounter, appropriate treatment as defined by each numerator criteria would be assessed from the time of ED arrival. The issue of the measure not excluding cases where the STEMI develops during the ED encounter but the measure still assesses appropriate treatment starting from ED arrival time, has been brought to CMS’s attention. The measure developer and CMS will consider refinements in a future annual update. 3. The measure does not currently exclude hospice patients or patients who refuse treatment. CMS and the measure developer will consider this measure refinement a future Annual Update.