STEMI - PCI not medically necessary

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    • Type: Hosp Outpt eCQMs - Hospital Outpatient eCQMs
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • Julie-Marie Lebbie
    • VMFH
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      Thank you for your inquiry regarding CMS996v5, Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED).

      The updated version 6 STEMI measure specification for the 2026 reporting period have denominator exceptions for ED encounters with a documented reason (such as not indicated) for (i) not administering fibrinolytic therapy within 30 minutes of ED arrival or (ii) not performing a PCI within 90 minutes of ED arrival. ED encounters with a documented reason for not administering fibrinolytic therapy or not performing a PCI within the abovementioned timeframes are still included in the measure; however, providers are not penalized for not meeting the numerator requirements. The updated measure specifications are available in the eCQI Resource Center: [https://ecqi.healthit.gov/ecqm/hosp-outpt/2026/cms0996v6?qt-tabs_measure=measure-information].

      Reasons for not performing a PCI are captured using the “Procedure, Not Performed” data type together with 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. The value sets cover scenarios where a PCI is not indicated or appropriate. These value sets can be found in the Value Set Authority Center (VSAC) by searching each value set’s OID [https://vsac.nlm.nih.gov/welcome]. Please note that you may need to create a free account to view these codes.
      Show
      Thank you for your inquiry regarding CMS996v5, Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). The updated version 6 STEMI measure specification for the 2026 reporting period have denominator exceptions for ED encounters with a documented reason (such as not indicated) for (i) not administering fibrinolytic therapy within 30 minutes of ED arrival or (ii) not performing a PCI within 90 minutes of ED arrival. ED encounters with a documented reason for not administering fibrinolytic therapy or not performing a PCI within the abovementioned timeframes are still included in the measure; however, providers are not penalized for not meeting the numerator requirements. The updated measure specifications are available in the eCQI Resource Center: [ https://ecqi.healthit.gov/ecqm/hosp-outpt/2026/cms0996v6?qt-tabs_measure=measure-information ]. Reasons for not performing a PCI are captured using the “Procedure, Not Performed” data type together with 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. The value sets cover scenarios where a PCI is not indicated or appropriate. These value sets can be found in the Value Set Authority Center (VSAC) by searching each value set’s OID [ https://vsac.nlm.nih.gov/welcome ]. Please note that you may need to create a free account to view these codes.
    • CMS0996v5

      For OP40/CMS996 - STEMI- We ask for clarification on coding for situations that are  impacting our Door-to-Balloon (D2B) metric:

      ST Elevation without Medically Necessary PCI: Patients present with ST elevation, but providers deem PCI not medically necessary after evaluation.

      • Question: How should these patients be coded to exclude them from D2B metrics without misrepresenting the initial ST elevation finding? Is there an exclusion code?

      Accurate coding is crucial for our D2B metrics, quality improvement, and data integrity. Your guidance is highly appreciated.

            Assignee:
            Mathematica EH eCQM Team
            Reporter:
            Julie-Marie Lebbie
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