Thank you for your feedback for CMS996: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). Our understanding of the issues you describe is the following: - Issue #1: The patient has a STEMI diagnosis, but a PCI is not indicated because the patient has clear coronaries. - Issue #2: The patient is initially diagnosed with STEMI, but is found to not have STEMI on a subsequent EKG reading. - Issue #3: The patient has a STEMI diagnosis, but a CABG is performed rather than a PCI. - Issue #4: The patient is included in the measure denominator due to a previous STEMI diagnosis although the ED encounter is not STEMI-related Regarding the first three issues you list, the updated Version 6 STEMI measure specifications for the 2026 reporting period have denominator exceptions for ED encounters with a documented reason for (i) not administering fibrinolytic therapy within 30 minutes of ED arrival or (ii) not performing a PCI within 90 minutes of ED arrival. Please note that, unlike denominator exclusions, denominator exceptions are still included in the measure; however, providers are not penalized for not meeting the numerator requirements. 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 “Procedure Not Indicated/Contraindicated” value set covers scenarios where a PCI is not clinically 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. Regarding the fourth issue, for context, we emphasize that the QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. A patient with a STEMI diagnosis may be captured in the measure in two ways, as indicated by the measure logic definition below found in the measure’s HTML file posted on the eCQI Resource Center [ https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS996-v6.3.000-QDM.html ]: ED Encounter with STEMI Diagnosis "ED Encounter During MP" EDEncounterinMP     where (exists (["Diagnosis": "STEMI"] DxSTEMI       where DxSTEMI.prevalencePeriod starts during EDEncounterinMP.relevantPeriod))     or (exists( EDEncounterinMP.diagnoses EncounterDiagnosis       where EncounterDiagnosis.code in "STEMI" )) First, a STEMI diagnosis can be pulled directly from the ED encounter if a STEMI diagnosis was coded at any point during the encounter. Second, the patient can have a diagnosis pulled from a claim, problem list, or other source in the EHR as long as the prevalencePeriod of the STEMI diagnosis started during the ED encounter relevantPeriod. PrevalencePeriod is an attribute of the “Diagnosis” datatype and signifies the onset dateTime to abatement dateTime of the STEMI diagnosis. RelevantPeriod is an attribute of the “Encounter, Performed” datatype and signifies the startTime that the encounter began (admission time) to the stopTime that the encounter ended (discharge time). To differentiate between active and historic diagnoses in the problem list and avoid misattribution, it is important to populate the onset and abatement times in the EHR and map these times to the appropriate QDM data elements.