Thank you for your inquiry regarding CMS996: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). The measure denominator captures ED encounters with a STEMI diagnosis among patients aged 18 years or older during a one-year measurement period. The measure defines appropriate STEMI treatment using three numerators: fibrinolytic therapy within 30 minutes of ED arrival, percutaneous coronary intervention (PCI) within 90 minutes of ED arrival, or discharge to acute care within 45 minutes of ED arrival. We understand the intent of your question is to determine if it is allowable to exclude ED transfer patients from the measure denominator that have multiple encounters. If a patient meeting the measure denominator does not meet criteria for measure denominator exclusions or exceptions, they should be captured in the measure denominator regardless of if they have multiple encounters documented in the EHR. The measure can handle cases in which a patient is transferred between multiple locations/hospitals under the same CMS Certification Number (CCN), depending on how the encounters are documented in the EHR: 1. If the patient had an ED encounter at the first location/hospital and an inpatient (IP) encounter at the second hospital, then the ED encounter at the first hospital could be captured in the measure numerator if the patient is discharged to acute care at the second hospital within 45 minutes of the first hospital’s ED arrival time. To be captured in this numerator criterion, we recommend that the ED encounter of the first hospital has proper documentation of both the ED discharge time and the ED discharge disposition of “Discharge to Acute Care Facility.” In this scenario, the second hospital’s IP encounter would not be captured in the measure denominator since it is the measure’s intent to only capture ED encounters that occurred during the measurement period. 2. If the EHR documents the patient as having two ED encounters – one at the first hospital and one at the second hospital – the first ED encounter could not meet the third numerator criterion: discharge to acute care within 45 minutes of ED arrival. To meet this numerator criterion, the first ED encounter must have a discharge disposition of “Discharge to Acute Care Facility.” Since the encounter at the second facility is an ED encounter rather than an IP encounter, the patient’s first ED encounter cannot have a discharge disposition of “Discharge to Acute Care Facility” regardless of the time stamp that the transfer occurred. If the end of the first ED encounter was properly documented with an ED discharge time and discharge disposition, the EHR would treat the ED encounter at the second hospital as a separate encounter. In this case, the second ED encounter could potentially meet the measure numerator if the patient received fibrinolytic therapy within 30 minutes of the patient’s ED arrival at the second hospital or PCI within 90 minutes of the patient’s ED arrival at the second hospital.