Thank you for your inquiry regarding CMS996v4: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). We want to emphasize that the measure specifications have undergone two Annual Update cycles since CMS996v4, and the latest version of the specifications (CMS996v6) reflect refinements. The most recent specifications can be found in the eCQI Resource Center here, and compared to earlier version of the measure: https://ecqi.healthit.gov/ecqm/hosp-outpt/2026/cms0996v6?qt-tabs_measure=measure-information   We have responded to each of the nine issues below with the corresponding issue number. 1. ED encounters during the measurement period are included if the encounter end time falls within the measurement period. Regarding the CMS spreadsheet, inquiries regarding the Quality Reporting Document Architecture (QRDA) should be shared to QualityNet Support: https://cmsqualitysupport.servicenowservices.com/qnet_qa?id=ask_a_question 2. The measure captures ED encounters, and patients can appear multiple times if the patient has multiple qualifying ED encounters during the measurement period. 3. Due to the limitations of the Quality Data Model (QDM), the measure specifications cannot account for clinical judgement or non-intervention decisions. The numerator outcomes for fibrinolytic therapy and transfer care both capture alternative treatments to PCI for STEMI patients. In CMS966v6, the measure developer introduced a denominator exception for emergency department encounters with a documented reason for not performing a PCI within 90 minutes of ED arrival. The measure developer will continue to refine the specifications to align with clinical best practices.                                                                                                                           4. We presume that by “exclusion” or “misclassification”, you are referring to the measure calculation excluding the ED encounter in this scenario. In the scenario that the patient received a PCI during the ED encounter, the patient will meet the numerator criteria as long as the procedure was completed within 90 minutes of ED arrival and is documented in accordance with the measure logic. 5. STEMI diagnosis are captured in three ways: (i) if STEMI is recorded as a diagnosis during the ED encounter, (ii) if the STEMI is in the problem list with a start time during the ED encounter, and (iii) if the ED encounter is linked to a STEMI diagnosis in the problem list. Please work with your EHR vendor to ensure the STEMI diagnosis is correctly documented. 6. Please refer to our response to Issue #5 above. 7. The third numerator criterion can be met even if a patient is transferred within 45 minutes of ED arrival to a hospital with the same CCN. To indicate that the ED encounter has ended, we recommend proper documentation of both the ED discharge time and the ED discharge disposition of “Discharge to Acute Care Facility.” 8. Starting with CMS966v5, the measure logic includes a denominator exception for ED encounters where the patient received fibrinolytic therapy at another facility within 24 hours. 9. Starting with CMS966v6, the measure logic includes a denominator exception for ED encounters with a documented reason for not performing a PCI within 90 minutes of ED arrival.

Inaccuracies in underreported performance metrics and misclassified cases, can distort quality scores and obscure the true value of care delivered. These discrepancies may impact organizational performance evaluations, regulatory compliance, and strategic decision-making.