Thank you for your follow-up inquiry regarding CMS996v6: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). The measure has several denominator exclusion criteria. The QDM datatypes and attributes associated with each exclusion can be found in the measure’s HTML file [ https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS996-v6.3.000-QDM.html ] and the eCQM Data Element Repository (DERep) on the eCQI Resource Center [ https://ecqi.healthit.gov/measure-data-elements/191286 ]. We recommend working with your EHR vendor to ensure proper mappings. Ventricular tachycardia, mentioned in the inquiry, is a clinical code found in the Cardiopulmonary Emergency value set OID: 2.16.840.1.113883.3.3157.4048. The measure excludes encounters in which the EHR shows evidence of ventricular tachycardia occurring 24 hours or less before the start of the ED encounter or during the ED encounter. The definition for this exclusion is represented under the "Cardiopulmonary Emergency" diagnosis, found in the HTML file, listed below: *Exclusion Diagnosis During ED Encounter or Within 24 Hours of ED Encounter Start*   "ED Encounter With STEMI Diagnosis" EDwSTEMI     with ( ["Diagnosis": "Aortic Dissection or Ruptured Aortic Aneurysm"]       union ["Diagnosis": "Neurologic impairment"]       union ["Diagnosis": "Cardiopulmonary Emergency"]       union ["Diagnosis": "Angina pectoris with documented spasm"]       union ["Diagnosis": "Ventricular aneurysm due to and following acute myocardial infarction (disorder)"]       union ["Diagnosis": "Aneurysm of heart"]       union ["Diagnosis": "Takotsubo cardiomyopathy (disorder)"]       union ["Diagnosis": "Takotsubo syndrome"]       ) ExclusionDx       such that ( ExclusionDx.prevalencePeriod starts during EDwSTEMI.relevantPeriod           or ExclusionDx.prevalencePeriod starts 24 hours or less before start of EDwSTEMI.relevantPeriod       ) To properly map ventricular tachycardia to trigger the exclusion mentioned above, there must be documentation in the EHR of the patient’s encounter having one of the ventricular tachycardia codes captured in the Cardiopulmonary Emergency value set. The onset and abatement times of the ventricular tachycardia diagnosis should be mapped to the “Diagnosis” Quality Data Model (QDM) datatype’s prevalencePeriod attribute. If the onset time of the ventricular tachycardia diagnosis occurs during the ED encounter or 24 hours or less before the start of the ED encounter, the encounter will be excluded from the measure denominator. If the diagnosis is documented in the EHR in a narrative format that does not include the clinical codes associated with an exclusion’s respective value set, the encounter will not be excluded from the measure denominator. A full list of ICD-10-CM and SNOMEDCT clinical codes captured in the Cardiopulmonary Emergency value set, can be found in the Value Set Authority Center [ https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4048/expansion/Latest ]. Please note, you may need to create a free account to view these codes. In relation to the “Diagnosis” datatype, we emphasize that the QDM does not prescribe the source of the diagnosis data in the EHR. Therefore, exclusion diagnoses may be found in the patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. Therefore, we highlight the importance of documenting the onset and abatement times of diagnoses in the EHR, associated with applicable clinical codes, to differentiate historic and active diagnoses and ensure appropriate attribution of diagnoses used in measure exclusions. Additionally, we notice the inquiry mentions that your facility “is trying to map this correctly so exclusion diagnoses occurring after the patient's ED encounter is correct.” We emphasize that it is not the measure’s intent to exclude encounters with exclusion conditions/procedures/diagnoses that occurred after the end of the ED encounter. The measure intends to exclude conditions that are pre-existing or that occurred during the ED encounter that prevent a patient from receiving timely and appropriate STEMI treatment. The timing components related to each denominator exclusion and exception criteria can be found in the HTML file. Please work with your EHR vendor to ensure appropriate mappings. Lastly, we recognize that conditions, procedures, and/or diagnoses captured in the measure’s exclusion criteria may occur at another facility with a different EHR system, prior to the patient’s current ED encounter at your facility. We recommend continuing to record these conditions/procedures/diagnoses in your EHR system during history-taking, and finding a place in your EHR system where you can manually document the diagnosis onset and abatement or procedure start and stop times. CMS and the measure developer will consider using the presentOnAdmissionIndicator and author dateTime attributes in a future annual update to ensure that encounters with pre-existing conditions are properly excluded.