Thank you for your inquiry regarding CMS996: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). We understand the intent of your question is to determine when documentation for not administering fibrinolytic therapy within 30 minutes of ED arrival or not performing a PCI within 90 minutes of arrival should occur to ensure that ED encounters meeting these denominator exceptions are not captured in the measure. The denominator exception for not administering fibrinolytic therapy within 30 minutes of ED arrival is defined using the negationRationale attribute of the “Medication, Not Administered” QDM datatype. Reasons for not administering fibrinolytic therapy are captured in the “Patient Refusal” (OID: 2.16.840.1.113883.3.117.1.7.1.93) and “Drug Intervention Not Indicated/Contraindicated” (OID: 2.16.840.1.113762.1.4.1282.1) value sets. The denominator exception uses the author dateTime attribute to indicate documentation of the time the decision to not administer fibrinolytic therapy occurred. To capture this denominator exception, documentation of the reason for not administering fibrinolytic therapy within 30 minutes of ED arrival must occur during the ED encounter relevantPeriod (or the time that the ED encounter began (admission time) to the time the ED encounter ended (discharge time)). Therefore, if documentation of the reason for not administering fibrinolytic therapy occurred outside of the ED encounter, such as in the inpatient setting, the denominator exception would not be triggered. The same logic is applicable to the denominator exception for not performing a PCI within 90 minutes of ED arrival, which is also defined using the negationRationale attribute of the “Procedure, Not Performed” QDM datatype. Reasons for not performing a PCI are captured in the Patient Refusal” (OID: 2.16.840.1.113883.3.117.1.7.1.93) and “Procedure Not Indicated/Contraindicated" (OID: 2.16.840.1.113762.1.4.1282.2) value sets. Similar to the denominator exception for not administering fibrinolytic therapy, this denominator exception also uses the author dateTime attribute to indicate documentation of the time the decision to not perform a PCI occurred. To capture this denominator exception, documentation of the reason for not performing a PCI within 90 minutes of ED arrival must occur during the ED encounter relevantPeriod. Therefore, if documentation of the reason for not performing a PCI occurs outside of the ED encounter, such as the inpatient setting, the denominator exception would not be triggered. From the case you describe in the inquiry where the patient is transferred from the ED to an inpatient encounter, we emphasize that if this transfer occurred within 45 minutes of ED arrival, the patient should fall into the measure’s third numerator criteria and these denominator exceptions would not be needed. We acknowledge the feedback that in some circumstances, documentation for not providing appropriate STEMI treatment may occur outside of the ED encounter, and can consider a refinement to make the documentation timing components of these denominator exceptions more flexible in a future Annual Update.