Bureau of Primary Health Care . Uniform Data System . Reporting Requirements for 2021 Health Center Data . PUBLIC BURDEN STATEMENT . The Uniform Data System (UDS) provides consistent information about health centers including patient characteristics, services provided, clinical pro cesses
2021 UDS MANUAL | Introduction. Introduction. This manual describes the annual Uniform Data System (UDS) reporting requirements for all health centers that.
Bureau of Primary Health Care
Uniform Data System Reporting Requirements for
2021 Health Center Data
PUBLIC BURDEN STATEMENT The Uniform Data System (UDS) provides consistent information about health centers including patient characteristics, services provided, clinical processes and health outcomes, patients' use of services, costs, and revenues. It is the source of unduplicated data for the entire scope of services included in the grant or designation for the calendar year. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0915-0193 and it is valid until 02/28/2023. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 238 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Health Resources and Services Administration (HRSA) Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov. DISCLAIMER "This publication lists non-federal resources to provide additional information to consumers. Neither the U.S. Department of Health and Human Services (HHS) nor the Health Resources and Services Administration (HRSA) has formally approved the non-federal resources in this manual. Listing these is not an endorsement by HHS or HRSA."
Letter from the Associate Administrator
Dear Health Center Program Participant:
The past year was marked by events that impacted every aspect of daily life. Health centers rose to the challenges presented, rapidly adapting to ensure primary health care services continued to be delivered to the communities they serve. Health centers scaled the adoption of telehealth, provided new lines of services, including screening and testing patients for COVID-19, and continued to deliver on the Health Center Program's mission of providing highquality care, all in the midst of a pandemic. The Health Resources and Services Administration (HRSA) and the American public are indebted to your hard work and perseverance. Your dedication to meeting community needs and patient care is why HRSA's Health Center Program has continued to thrive for over 50 years and will carry on the legacy of the late Dr. Jack Geiger.
A civil rights activist, Dr. Geiger co-founded the Community Health Center Movement, sharply focusing his work on tackling health disparities impacting underserved communities. Dr. Geiger envisioned a country where everyone has access to high-quality health care services, regardless of their ability to pay. And it's that guiding principle that remains the foundation for the Health Center Program today. In 2019, nearly 1,400 community-based and patientdirected health centers with more than 13,000 delivery sites delivered high-quality, affordable, and cost-effective health care to nearly 30 million people1. Over 1,000 health centers developed the capacity to diagnose and treat individuals with COVID-192, and, through HRSA's Expanding Capacity for Coronavirus Testing award, the Coronavirus Preparedness and Response Supplemental Appropriations Act, and funding to support training and COVID-19-related technical assistance, health centers were able to expand their testing capacity3 and communities across the country gained access to the screening and testing they needed.
These numbers help to tell the story of how health centers meet the medical needs of diverse communities far and wide. Data, including what we receive through the Uniform Data System (UDS) with technical guidance provided in this manual, are vital to further expanding health care access, assessing the quality of care provided, reducing health care costs, and addressing health disparities that adversely affect the communities health centers serve. Your contributions to ensuring UDS data is properly captured and reported in an accurate, timely, and complete fashion exemplify what helps shape the effectiveness of data-driven decision making in the Health Center Program.
I remain deeply appreciative of the leading role health centers are playing in turning the tide on COVID-19. I'm encouraging all health center staff and patients to receive their COVID-19 vaccinations. These vaccines are safe and effective in mounting protection from the novel coronavirus.
I would like to extend my gratitude once again for your commitment to underserved communities and vulnerable populations across our country through the Health Center Program.
Sincerely,
/James Macrae/
James Macrae Associate Administrator Bureau of Primary Health Care
1 UDS Health Center Trend Report. (2019). Accessed through the Electronic Handbooks. 2 Health Center COVID-19 Survey. (March 2021). https://bphc.hrsa.gov/emergency-response/coronavirus-health-center-data 3 HRSA Health Center Program. (2020). Fiscal Year 2020 Expanding Capacity for Coronavirus Testing (ECT) Supplemental Funding for Health Centers. https://bphc.hrsa.gov/program-opportunities/expanding-capacity-coronavirus-testing-supplementalfunding#:~:text=Fiscal%20year%20(FY)%202020%20Expanding,2019%20(COVID%2D19)
Bureau of Primary Health Care
Uniform Data System Reporting Requirements
For Calendar Year 2021 UDS Data
For help contact: 866-837-4357 (866-UDS-HELP), https://bphcdata.net/, or udshelp330@bphcdata.net
Health Resources and Services Administration Bureau of Primary Health Care
5600 Fishers Lane, Rockville, Maryland 20857
UDS SUPPORT CENTER, 866-UDS-HELP, UDSHELP330@BPHCDATA.NET
2021 Uniform Data System Manual Contents
Changes to the Reporting Requirements........10 Introduction ...................................................... 11
About the UDS ............................................... 11 What This Manual Includes............................11 General Instructions.........................................12 What to File .................................................... 12 What to Submit...............................................12 Calendar Year Reporting ................................ 13 In-Scope Reporting.........................................14 Due Dates and Revisions to Reports ..............14 How and Where to Submit Data.....................15 FAQs for the General Instructions.................. 16 Instructions for Tables that Report Visits, Patients, and Providers .................................................... 17 Countable Visits ............................................. 17
Documentation ........................................... 17 Independent Professional Judgment ........... 17 Behavioral Health Group Visits ................. 18 Location of Services Provided....................18 Counting Multiple Visits by Category of Service .................................................................... 18 Patient ............................................................. 19 Services and Individuals Not Reported on the UDS Report ................................................ 20 Provider .......................................................... 21 FAQs for the Instructions for Tables .............. 22 Instructions for ZIP Code Data.......................23 Patients by ZIP Code ...................................... 23
Table 3A: Patients by Age and by Sex Assigned at Birth................................................................... 27 Table 3B: Demographic Characteristics ........ 28
Patients by Hispanic or Latino/a Ethnicity and Race (Lines 18) ..................................................... 28
Hispanic or Latino/a Ethnicity ................... 28
Race ............................................................ 28
Patients Best Served in a Language Other than English (Line 12)............................................ 29
Patients by Sexual Orientation (Lines 1319).... ........................................................................ 29
Patients by Gender Identity (Lines 2026)..... 30
FAQs for Tables 3A and 3B........................... 31
Table 3A: Patients by Age and by Sex Assigned at Birth................................................................ 34
Table 3B: Demographic Characteristics......... 35
Instructions for Table 4: Selected Patient Characteristics .................................................. 36
Income as a Percent of Poverty Guideline, Lines 1 6...................................................................... 36
Principal Third-Party Medical Insurance, Lines 7 12.................................................................... 36
None/Uninsured (Line 7) ........................... 37
Medicaid (Line 8a) ..................................... 37
CHIP-Medicaid (Line 8b) .......................... 37
Medicare (Line 9)....................................... 38
Dually Eligible (Medicare and Medicaid) (Line 9a)............................................................... 38
Other Public Insurance (Non-CHIP) (Line 10a) .................................................................... 38
ZIP Code of Specific Groups ..................... 23
Other Public Insurance CHIP (Line 10b) ... 39
Unknown ZIP Code .................................... 23
Private Insurance (Line 11) ........................ 39
Ten or Fewer Patients in ZIP Code ............ 24
Managed Care Utilization, Lines 13a13c ..... 39
Instructions for Type of Insurance..................24
Member Months ......................................... 39
Insurance Categories .................................. 24
Special Populations, Lines 1426 .................. 40
FAQs for Patients by ZIP Code Table............25 Table: Patients by ZIP Code ........................... 26 Instructions for Tables 3A and 3B .................. 27
Total Migratory and Seasonal Agricultural Workers and Their Family Members, Lines 14 16................................................................ 41
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Total Homeless Patients, Lines 1723 .......41
Total School-Based Health Center Patients, Line 24 ................................................................ 43
Total Veterans, Line 25 .............................. 43
Total Patients Served at a Health Center Service Delivery Site Located in or Immediately Accessible to a Public Housing Site, Line 26. .................................................................... 43
FAQs for Table 4............................................44
Table 4: Selected Patient Characteristics........47
Table 4: Selected Patient Characteristics (continued)...................................................... 48
Instructions for Table 5: Staffing and Utilization ............................................................................ 49
Table 5: Staffing and Utilization .................... 49
Personnel Full-Time Equivalents (FTEs), Column A ..................................................................... 49
Identifying Employment Type and Calculating FTEs ........................................................... 50
Reporting FTEs in the Appropriate Line on Table 5 .................................................................. 50
Personnel by Major Service Category ........ 51
Visits, Columns B and B2 .............................. 57
Clinic Visits, Column B ............................. 57
Virtual Visits, Column B2 .......................... 57
Visits Purchased from Non-Personnel Providers on a Fee-For-Service Basis.........................58
Visit Considerations by Personnel Line ..... 58
DO NOT Report Visits or Patients for Services Provided by the Following: ........................ 61
Patients, Column C ......................................... 61
Selected Service Detail Addendum ................62
Providers, Column A1 ................................ 62
Clinic Visits, Column B ............................. 62
Virtual Visits, Column B2 .......................... 63
Patients, Column C ..................................... 63
FAQs for Table 5 and Selected Service Detail Addendum ...................................................... 63
Table 5: Staffing and Utilization .................... 67
Table 5: Staffing and Utilization (continued)..... ........................................................................ 68
Table 5: Selected Service Detail Addendum...... ........................................................................ 69
Instructions for Table 6A: Selected Diagnoses and Services Rendered ............................................ 70
Selected Diagnoses, Lines 120f.................... 70
Selected Diagnoses Visits and Patients, Columns A and B ...................................................... 70
Selected Tests/Screenings, Lines 2126d ...... 71
Selected Tests/Screenings Visits and Patients, Columns A and B ....................................... 71
Dental Services, Lines 2734 ......................... 72
Dental Services Visits and Patients, Columns A and B .......................................................... 72
Services Provided by Multiple Entities .......... 72
FAQs for Table 6A......................................... 73
Table 6A: Selected Diagnoses and Services Rendered ........................................................ 77
Selected Diagnoses......................................... 77
Selected Services Rendered ........................... 79
Instructions for Tables 6B and 7..................... 82
Column Logic Instructions............................. 82
Column A (A, 2A, or 3A): Number of Patients in the Denominator ......................................... 82
Column B (B, 2B, or 3B): Number of Charts/Records Sampled or EHR Total...... 83
Column C (C or 2C) or 3F: Number of Charts/Records Meeting the Numerator Criteria .................................................................... 84
Criteria vs. Exceptions and Exclusions in HITs/EHRs vs. Chart Reviews ................... 84
And vs. Or .................................................. 85
Detailed Instructions for Clinical Quality Measures ........................................................................ 85
Instructions for Table 6B: Quality of Care Measures ........................................................... 86
Table 6B: Quality of Care Measures .............. 86
Sections A and B: Demographic Characteristics of Prenatal Care Patients..................................... 86
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Prenatal Care by Referral Only (check box) .. .................................................................... 87
Section A: Age of Prenatal Care Patients (Lines 16)............................................................. 87
Section B: Early Entry into Prenatal Care (Lines 79), No eCQM .......................................... 88
Sections C through M: Other Quality of Care Measures ......................................................... 89
Childhood Immunization Status (Line 10), CMS117v9.................................................. 90
Cervical Cancer Screening (Line 11), CMS124v9 .................................................................... 91
Breast Cancer Screening (Line 11a), CMS125v9 .................................................................... 92
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (Line 12), CMS155v9 ............ 94
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan (Line 13), CMS69v9...................................95
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (Line 14a), CMS138v9.................................................. 96
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease (Line 17a), CMS347v4.................................................. 98
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet (Line 18), CMS164v7 .................................................................... 99
Colorectal Cancer Screening (Line 19), CMS130v9................................................ 100
HIV Linkage to Care (Line 20), No eCQM102
HIV Screening (Line 20a), CMS349v3....103
Preventive Care and Screening: Screening for Depression and Follow-Up Plan (Line 21), CMS2v10.................................................. 104
Depression Remission at Twelve Months (Line 21a), CMS159v9....................................... 106
Dental Sealants for Children between 69 Years (Line 22), CMS277v0...............................107
FAQs for Table 6B ....................................... 108
Table 6B: Quality of Care Measures ............ 112
Instructions for Table 7: Health Outcomes and Disparities ....................................................... 116
Table 7: Health Outcomes and Disparities Measures ...................................................................... 116
Race and Ethnicity Reporting....................... 116
Section A: Deliveries and Birth Weight....... 117
HIV-Positive Pregnant Patients, Top Line (Line 0) ...................................................................... 117
Deliveries Performed by Health Center Provider (Line 2)......................................................... 117
Deliveries and Birth Weight Data by Race and Hispanic or Latino/a Ethnicity, Columns 1a1d ...................................................................... 117
Prenatal Care Patients and Referred Prenatal Care Patients Who Delivered During the Year (Column 1a) ............................................. 117
Birth Weight of Infants Born to Prenatal Care Patients Who Delivered During the Year (Columns 1b1d)...................................... 118
Sections B and C: Other Health Outcome and Disparity Measures....................................... 119
Controlling High Blood Pressure (Columns 2a 2c), CMS165v9 ........................................ 120
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9.0 percent) (Columns 3a3f), CMS122v9 ............................................... 121
FAQs for Table 7.......................................... 122
Table 7: Health Outcomes and Disparities... 124
Instructions for Table 8A: Financial Costs ........ .......................................................................... 127
Table 8A: Financial Costs ............................ 127
Column Reporting Requirements ................. 127
Column A: Accrued Costs........................ 127
Column B: Allocation of Facility Costs and NonClinical Support Service Costs................. 127
Column C: Total Cost After Allocation of Facility and Non-Clinical Support Services ... .................................................................. 127
Cost Center Line Reporting Requirements .. 128
Medical Personnel Costs (Line 1) ............ 128
Medical Lab and X-Ray Costs (Line 2) ... 128
Other Direct Medical Costs (Line 3) ........ 128
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Total Medical (Line 4)..............................129 Other Clinical Services (Lines 510) .......129 Dental (Line 5) ......................................... 129 Mental Health (Line 6) ............................. 129 Substance Use Disorders (Line 7) ............ 129 Pharmacy (Not Including Pharmaceuticals) (Line 8a) ............................................................. 129 Pharmaceuticals (Line 8b) ........................ 130 Other Professional (Line 9) ...................... 130 Vision (Line 9a)........................................130 Total Other Clinical (Line 10) .................. 130 Enabling (Lines 11a11h, 11) .................. 130 Total Enabling Services (Line 11)............131 Other Program-Related (Line 12).............131 Quality Improvement (QI) (Line 12a) ...... 131 Total Enabling, Other Program-Related, and Quality Improvement Services (Line 13) ....... .................................................................. 131 Facility Costs (Line 14) ............................ 131 Non-Clinical Support Services Costs (Line 15) .................................................................. 132 Total Facility and Non-Clinical Support Services (Line 16) ................................................... 132 Total Accrued Cost (Line 17) ................... 132 Value of Donated Facilities, Services, and Supplies (Line 18, Column C) .................. 132 Total with Donations (Line 19) ................ 133 Facility and Non-Clinical Support Services Allocation Instructions ................................. 133 Facility ...................................................... 133 Non-Clinical Support Services ................. 133 FAQs for Table 8A ....................................... 134 Table 8A: Financial Costs ............................ 137 Instructions for Table 9D: Patient Service Revenue .......................................................................... 139 Table 9D: Patient Service Revenue .............. 139 Rows: Payer Categories and Form of Payment .. ...................................................................... 139 Form of Payment ...................................... 139
Payer Categories....................................... 140 Columns: Charges, Payments, and Adjustments Related to Services Delivered ...................... 142
Column A: Full Charges This Period ....... 142 Column B: Amount Collected This Period .... .................................................................. 143 Columns C1C4: Retroactive Settlements, Receipts, or Paybacks............................... 143 Column D: Adjustments........................... 144 Column E: Sliding Fee Discounts ............ 145 Column F: Bad Debt Write-Off ............... 145 Total Patient Service Revenue (Line 14) . 145 FAQs for Table 9D....................................... 146 Table 9D: Patient Service Revenue.............. 148 Instructions for Table 9E: Other Revenue... 150 Table 9E: Other Revenue ............................. 150 BPHC Grants................................................ 150 Health Center Program Grants, Lines 1a through 1e .............................................................. 150 Total Health Center Program (Line 1g) ... 151 Capital Development Grants (Line 1k) .... 151 COVID-19 Supplemental Funding........... 151 Total BPHC Grants (Line 1) .................... 151 Other Federal Grants .................................... 151 Ryan White Part C--HIV Early Intervention Grants (Line 2) ......................................... 151 Other Federal Grants (Line 3) .................. 152 Medicare and Medicaid EHR Incentive Grants for Eligible Providers (Line 3a)................ 152 Provider Relief Fund (Line 3b) ................ 152 Total Other Federal Grants (Line 5)......... 152 Non-Federal Grants or Contracts ................. 152 State Government Grants and Contracts (Line 6) .................................................................. 152 State/Local Indigent Care Programs (Line 6a) .................................................................. 153 Local Government Grants and Contracts (Line 7) .................................................................. 153
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Foundation/Private Grants and Contracts (Line 8) .................................................................. 153
Total Non-Federal Grants and Contracts (Line 9) .................................................................. 153
Other Revenue (Line 10) .......................... 153
Total Other Revenue (Line 11).................154
FAQs for Table 9E ....................................... 154
Table 9E: Other Revenues ............................ 156
Appendix A: Listing of Personnel ................. 157 Appendix B: Special Multi-Table Situations...... .......................................................................... 162
Contracted Care (specialty, dental, mental health, etc.) ............................................................... 163
Services Provided by a Volunteer Provider..164
Interns and Residents....................................164
Women, Infants, and Children (WIC) .......... 165
In-House Pharmacy or Dispensary Services for Health Center Patients .................................. 165
In-House Pharmacy for Community (i.e., for nonpatients) ........................................................ 166
Contract Pharmacy Dispensing to Health Center Patients, Generally Using 340B Purchased Drugs ...................................................................... 166
Donated Drugs, Including Vaccines ............. 167
Clinical Dispensing of Drugs ....................... 167
ADHC and PACE.........................................168
Medi-Medi/Dually Eligible .......................... 168
Certain Grant-Supported Clinical Care Programs: BCCCP, Title X, etc. .................................... 169
State or Local Indigent Care Programs.........169
Workers' Compensation ............................... 169
Tricare, Trigon, Public Employees Insurance, Etc. ...................................................................... 170
Contract Sites................................................ 170
The Children's Health Insurance Program (CHIP) ...................................................................... 171
Carve-Outs.................................................... 171
Incarcerated Patients.....................................171
HIT/EHR Personnel and Costs ..................... 172
Issuance of Vouchers for Payment of Services .. ...................................................................... 173
New Start or New Access Point (NAP)........ 174
Relationship Between Personnel on Table 5 and Costs on Table 8A ........................................ 174
Relationship Between Insurance on Table 4 and Revenue on Table 9D ................................... 175
Relationship Between Prenatal Care on Table 6B and Deliveries on Table 7............................. 175
Relationship Between Race and Ethnicity on Tables 3B and 7 ....................................................... 176
Appendix C: Sampling Methodology for Manual Patient Health Record Reviews..................... 177
Introduction .................................................. 177
Random Sample ........................................... 177
Step-by-Step Process for Reporting Clinical Quality Measures Using a Random Sample.............. 177
Step 1: Identify the Patient Population (the Denominator) ........................................... 177
Step 2: Prepare a Random Sample to the Correct Sample Size .............................................. 178
Step 3: Review the Sample of Patient Health Records to Determine Whether Each Record Has Met the Numerator Criteria for the Clinical Quality Measure ....................................... 178
Step 4: Replace Patients You Exclude from the Sample ...................................................... 178
Methodology for Obtaining a Random Sample . ...................................................................... 178
Option #1: Random Number List ............. 179
Option #2: Interval ................................... 180
Appendix D: Health Center Health Information Technology (HIT) Capabilities...................... 181
Introduction .................................................. 181
Questions ...................................................... 181
Appendix E: Other Data Elements ............... 186
Introduction .................................................. 186
Questions ...................................................... 186
Appendix F: Workforce................................. 189
Introduction .................................................. 189
Questions ...................................................... 189
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Appendix G: Health Center Resources ........192
UDS Production Timeline and Report Availability ...................................................................... 194
UDS CQMs and National Programs Crosswalk ................................................................... ...195
Appendix H: Glossary.................................... 197 Appendix I: Acronyms................................... 201
Changes to the Reporting Requirements
This section outlines critical reporting instruction changes made since the original release (April 7, 2021) of this manual. Use the updated manual to prepare and submit the calendar year UDS Report.
· Page 1: The front cover includes the date of re-release. · Page 10: The list of page numbers with corresponding changes included in this release. · Page 80: Table 6A includes additional coronavirus (SARS-CoV-2) vaccine codes. · Page 92: Cervical Cancer Screening measure age limit for the denominator inclusion has been clarified. · Page 95: Body Mass Index (BMI) Screening and Follow-Up Plan measure age for the denominator inclusion
has been clarified. · Page 204: The date on the back cover has been changed from April 7, 2021 to August 16, 2021.
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Introduction
This manual describes the annual Uniform Data System (UDS) reporting requirements for all health centers that receive federal award funds ("awardees") under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b) ("section 330"), as amended (including sections 330(e), (g), (h), and (i)), as well as for health centers considered Health Center Program look-alikes. Look-alikes DO NOT receive regular federal funding under section 330 of the PHS Act (although they may receive funding during public health emergencies, such as COVID-19), but meet the Health Center Program requirements for designation under the program (42 U.S.C. 1395x(aa)(4)(A)(ii) and 42 U.S.C. 1396d(l)(2)(B)(ii)). Certain health centers funded under the Health Resources and Services Administration's (HRSA) Bureau of Health Workforce (BHW) are also required to complete the UDS.
Unless otherwise noted, for the remainder of this manual the term "health center" will refer to all the entities listed above that are required to submit a UDS Report.
ABOUT THE UDS
The UDS is a standard data set that is reported annually and provides consistent information about health centers. This core set of information encompasses patient characteristics, services provided, clinical processes and health outcomes, patients' use of services, staffing, costs, and revenues for the calendar year. It is the source of unduplicated data for the entire scope of services included in the grant or designation for the calendar year. If the health center brings services or service delivery sites into scope of project during the calendar year, data must be included from the period after the date of the scope change.
HRSA routinely reports these data and related analyses, making them available to health centers in HRSA's Electronic Handbooks (EHBs) and to the public through HRSA's BPHC website.
WHAT THIS MANUAL INCLUDES
This manual includes reporting requirements and resources to assist with completion of the UDS Report and that apply to the calendar year 2021 UDS Report due February 15, 2022.
Reporting requirements include the approved UDS changes for the calendar year. The 2021 Program Assistance Letter (PAL) 2020-07
provides an overview of major changes.
nkSampling methods for selecting patient charts for clinical quality measure reporting are provided in
Appendix C.
A list of personnel by service category and by job title who may be eligible to produce countable "visits" for the UDS is shown in
Appendix A.
k
Resources and supports to assist health centers, including links to
electronic clinical quality measures (eCQMs), are provided
in Appendix G.
Issues that affect multiple tables are addressed in Appendix B.
A glossary of key terms is available in Appendix H. Acronyms used throughout the UDS Manual are defined in
Appendix I.
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General Instructions
WHAT TO FILE
The UDS includes two parts that health centers submit through the EHBs:
1) All health centers use the Universal Report, which consists of the UDS tables, the HIT Form, the Other Data Elements Form, and the Workforce Form.
2) Health Center Program awardees that receive section 330 grants under multiple program funding authorities (Community Health Center [CHC] [330(e)] program, Migrant Health Center [MHC] [330(g)] program, Health Care for the Homeless [HCH] [330(h)] program, and/or Public Housing Primary Care [PHPC] [330(i)]) also complete separate Grant Reports.
o The Grant Reports provide data comparable to the Universal Report for Tables 3A, 3B, 4, 6A, and part of Table 5.
o Grant Reports are only completed for the portion of the program that falls within the scope of a project funded under a particular funding authority.
o Awardees DO NOT file a separate Grant Report for the scope of project supported under the CHC (330(e)) program.
The EHBs reporting system automatically identifies all the reports needed to meet the UDS reporting requirements. Please contact the Health Center Program Support line at 877-464-4772 if there appear to be errors.
The Universal Report is an unduplicated count of all patients served by the health center regardless of funding source; the Grant Report is a subset of patients reported on the Universal Report served under a special population funding authority. Thus, no cell in a Grant Report may have a number larger than the same cell in the Universal Report.
Report all the data for any patient who receives services under sections 330(g), (h), or (i) in the proper Grant Report. Include services provided to these patients regardless of the funding source.
WHAT TO SUBMIT
The UDS includes 11 tables and 3 forms (in the appendices) that provide consistent demographic, clinical, operational, and financial data. Health centers must complete the following:
Table
Service Area ZIP Code Table: Patients by ZIP Code Patient Profile Table 3A: Patients by Age and by Sex Assigned at Birth Table 3B: Demographic Characteristics
Table 4: Selected Patient Characteristics
Data Reported
Universal Report
Service Area
Service Area
Patients served reported by ZIP code and by primary third-party medical insurance source, if any
X
Patient Profile
Patient Profile
Patients by age and by sex assigned at birth
X
Patients by race, Hispanic or Latino/a ethnicity,
language barriers, sexual orientation, and gender
X
identity
Patients by income (as measured by percentage of
the federal poverty guidelines [FPG]) and primary
third-party medical insurance; the number of
X
"special population" patients receiving services;
and managed care enrollment, if any
Grant Reports Service Area
Not included in grant reports
Patient Profile
X
X
X
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Table
Staffing and Utilization
Table 5: Staffing and Utilization
Table 5 Addendum: Selected Service Detail Addendum
Clinical
Table 6A: Selected Diagnoses and Services Rendered
Table 6B: Quality of Care Measures Table 7: Health Outcomes and Disparities Financial Table 8A: Financial Costs
Table 9D: Patient Service Revenue
Table 9E: Other Revenue Other Appendix D: Health Information Technology (HIT) Capabilities Form Appendix E: Other Data Elements Form
Appendix F: Workforce Form
Data Reported
Staffing and Utilization The annualized full-time equivalent (FTE) of program personnel by position category, in-person and virtual visits by provider type, patients by service type Mental health services provided by medical providers; substance use disorder services provided by medical and mental health providers Clinical Visits and patients for selected medical, mental health, substance use disorder, vision, and dental diagnoses and services
Clinical quality-of-care measures
Health outcome measures by race and ethnicity
Financial Direct and indirect expenses by service categories Full charges, collections, and adjustments by payer type; sliding fee discounts; and patient bad debt write-offs Other, non-patient service revenue Other Form
HIT capabilities, including the use of electronic health record (EHR) information
Medication-assisted treatment (MAT), telehealth, and outreach and enrollment assists Health center workforce training and use of provider and personnel satisfaction surveys
Universal Report
Staffing and Utilization
X
X
Clinical
X
X X
Financial
X X X
Other Form
X
X X
Grant Reports
Staffing and Utilization
partial
Not included in grant reports Clinical
X
Not included in grant reports Not included in grant reports
Financial Not included in grant reports Not included in grant reports Not included in grant reports
Other Form Not included in grant reports
Not included in grant reports Not included in grant reports
The UDS Support Center is available to provide training, technical assistance, and resources about the UDS data and reporting requirements. Contact the Support Center at 1-866-UDS-HELP or udshelp330@bphcdata.net.
CALENDAR YEAR REPORTING
Who Reports UDS
What is Reported
· All health centers funded or designated in whole or in part before October 1, 2021
· Approved in-scope activities from January 1 through December 31, 2021
· Report even if no grants were drawn down for some or all programs during the calendar year.
How to Report
· Through the Electronic Handbooks (EHBs) starting January 1, 2022
· Preliminary Reporting Environment (PRE) and offline tools are available in Fall 2021.
When to Report
· January 1 through February 15, 2022
· UDS Report reviews are conducted from February 15 through March 31, 2022.
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The UDS is a calendar year report. Health centers--including those whose designation or funding begins, either in whole or in part, after January 1--must report in-scope activities for the entire calendar year. Similarly, health centers with a fiscal year or grant period other than January 1 to December 31 will still report on the calendar year, not on their fiscal or grant year. If one or more service delivery sites of a health center designated as a look-alike received section 330 New Access Point (NAP) funding before October 2021, exclude all the data related to those funded service delivery sites from the look-alike UDS Report for 2021 and report the data related to the funded service delivery sites in the awardee UDS Report for 2021. If the entire look-alike program became funded before October 2021, report only an awardee UDS Report for the year.
Health centers whose designation or funding ends during the year should discuss their reporting requirements with their project officer.
No UDS Report is filed if the health center was funded or designated for the first time on or after October 1 of the calendar year.
IN-SCOPE REPORTING
All health centers must submit data that reflects activities in the HRSA health center project, as defined in approved applications and reflected in the official Notice of Award/Designation. For organizations that operate programs or service delivery sites that are out-of-scope, limit the reporting to the approved scope of project only.
DUE DATES AND REVISIONS TO REPORTS
The period for submission of complete and accurate UDS Reports is January 1 through February 15, 2022, 11:59 p.m. local time. From February 15 through March 31, 2022, a Health Center Program UDS Reviewer will review your report and, as needed, help you explain or correct the reported data. The UDS Reviewer sends communications and data change requests through EHBs via a non-HRSA.gov email address to the health center contact listed in the EHBs. Communicate directly with the assigned UDS Reviewer during this time to address questions they have raised. Final, corrected submissions are due no later than March 31, 2022. HRSA does not accept changes after this date. HRSA may grant a reporting exemption under extraordinary circumstances, such as the physical destruction of a health center. Health centers must request such exemptions directly from the BPHC Office of Quality Improvement through Health Center Program Support. For report deadline and exemption help at any time, please contact Health Center Program Support at 877-4644772.
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HOW AND WHERE TO SUBMIT DATA
Health center personnel use their username and password to log into the EHBs to complete and submit their UDS Reports. The system supports the use of standard web browsers4 and it provides electronic forms necessary to complete the Reports. The Preliminary Reporting Environment (PRE) provides early access to the EHBs and is available in the fall. This allows health centers to:
· enter available UDS data, · help identify potential data reporting errors, and · provide additional preparation time to compile UDS data. To facilitate a team-based approach, there are also offline reporting templates available within the EHBs. For more information on these tools, visit the UDS Modernization Initiative web page.
Health centers are required to designate one person as the UDS contact. The UDS contact receives all communications about the UDS Report. This person may be asked to explain the data reported on the UDS tables during the review. Be sure the UDS contact information is updated in the EHBs.
Health centers grant individual personnel "view" or "edit" privileges in the EHBs. These privileges apply to the whole report, not just specific tables. Health centers may give data entry responsibility to several people, each using separate login credentials. Health center personnel with EHBs access can work on the forms in sections, saving interim or partial versions online as they work and returning to complete them later.
The EHBs saves user progress until the health center completes all tables, runs system checks on the data, and makes a formal submission. The chief executive officer (CEO) or project director usually does this but may delegate the authority to someone else. At the time of submission, the UDS requires the submitter to acknowledge that the health center reviewed and verified the accuracy and validity of the data. Only submit completed reports into the EHBs. To ensure accuracy, the EHBs checks for potential inconsistencies or questionable data. The system provides a summary of which tables are complete, as well as a list of audit questions. Health center personnel must address each of the data audit findings, even if the audit question does not apply to their health center's unique circumstances. If personnel believe the data is correct as submitted, they should clearly explain any unique circumstances.
Failure to submit a timely, accurate, and complete UDS Report by February 15, 2022, 11:59 p.m. (local time) will result in a condition being placed on your grant award. Additional restrictions, including the requirement that all drawdowns of Health Center Program grant award funds from the Payment Management System (PMS) have the prior approval of the HRSA Division of Grants Management Operations (DGMO) and/or limits on future funding (e.g., base adjustments), may also be placed on your grant award.
Note: Retain health center UDS reporting backup documentation and files for a minimum of one year or through a date determined by the health center.
Please refer to Appendix G: Health Center Resources for resources that may be helpful for completing the UDS Report.
4 While most browsers should work with the EHBs, it is certified to work with Internet Explorer (IE) Version 8.0 through 11.0 or Firefox 3.6 or higher. Health centers having a problem with other browsers should consider using IE-8, 9, 10, or 11 or Firefox 3.6 or higher for this task. More information about EHBs' recommended settings is available on the EHBs website.
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FAQS FOR THE GENERAL INSTRUCTIONS
1. Do we report only the services provided to patients under HCH, MHC, or PHPC grant funds on the Grant Report? No. Include activity for all patients described in the approved grant scope of project, regardless of the funding source. For example, if patients experiencing homelessness receive medical services in the 330(h)-supported homeless medical van, report this activity on the Homeless Grant Report tables. If patients experiencing homelessness receive dental services at the clinic, where 330(h) funds are not used, this activity would also be reported on the Homeless Grant Report tables regardless of the dental funding source.
2. When do we complete a Universal Report and a Grant Report? In summary, health centers that receive funds under only one BPHC funding authority complete the Universal Report and no Grant Reports. Health centers funded through multiple BPHC funding authorities complete a Universal Report for the combined projects and a separate Grant Report for activity covered by their MHC, HCH, and/or PHPC program grant(s). Examples include the following: · A CHC awardee that also has HCH funding completes a Universal Report for all in-scope activity and a Grant Report for activity under the HCH program, but it does not complete a Grant Report for the CHC funding. · A CHC awardee that also has MHC and HCH funding completes a Universal Report, a Grant Report for the HCH program, and a Grant Report for the MHC program. · An HCH awardee that also receives PHPC funding completes a Universal Report and two Grant Reports--one for the HCH program and one for the PHPC program. · An HCH awardee that receives no other Health Center Program funding will file a Universal Report and will not file a Grant Report.
3. We had a service delivery site that closed and is no longer in-scope. Do we report service delivery sites or services that are removed from scope of project in the UDS Report? Yes. If services or service delivery sites are removed from your scope of project, report on all activities (visits, personnel, revenue, etc.) up until the date they were removed.
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Instructions for Tables that Report Visits, Patients, and Providers
Health centers serve many individuals in different ways. Not all individuals, encounters, and health center personnel will count in the UDS Report. The following section defines countable visits, patients, and providers for the UDS.
COUNTABLE VISITS
Visits determine who to count as a patient on the ZIP Code Table and Tables 3A, 3B, 4, 5, 6A, 6B, and 7. Report visits by type of provider on Table 5 and for selected diagnoses and selected services on Table 6A.
Countable visits are encounters between a patient and a licensed or credentialed provider who exercises independent professional judgment in providing services that are:
· documented, · individual,5 · in-person or virtual.6 Count only visits that meet all these criteria. Services must be provided by an individual classified as a "provider" for purposes of providing countable visits. Not all health center personnel who interact with patients qualify as a provider. Appendix A provides a list of health center personnel and the usual status of each as a provider or non-provider for UDS reporting purposes.
Visits provided by contractors and paid for by or billed through the health center are counted in the UDS if they meet all other criteria. These include migrant voucher visits, as well as outpatient or inpatient specialty care associated with an at-risk managed care contract. In these instances, if the visit is not documented in the patient's health record, a summary of the visit (rather than the complete record) must appear in the patient's health record, including all appropriate Current Procedural Terminology (CPT) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes.
Below are definitions and criteria for reporting visits. Table 5 provides further clarifications. See Clinic Visits, Column B.
Documentation
Health centers must record the service and associated patient information, in print or electronic form, in a system that permits ready retrieval of current data for the patient. The patient health record does not have to be complete to meet this standard.
Independent Professional Judgment
Providers must be acting on their own, not assisting another provider, when serving the patient.
5 An exception is allowed for behavioral health visits, which may be conducted in a group setting. 6 Only interactive, synchronous audio and/or video telecommunication systems that permit real-time communication between a distant provider and a patient may be considered and coded as telemedicine services. The term "telehealth" includes telemedicine services but encompasses a broader scope of remote health care services. Telemedicine is specific to remote clinical services, whereas telehealth may include remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services.
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Independent professional judgment is the use of the professional skills gained through formal training and experience and unique to that provider or other similarly or more intensively trained providers.
Behavioral Health Group Visits
A behavioral health provider who provides services to several patients simultaneously receives credit for a visit for each individual only if the service is documented in each patient's health record.
Examples of "group visits" include family therapy or counseling sessions, group mental health counseling, and group substance use disorder counseling where several people receive services that are documented in each patient's health record.
Other considerations:
· The health center normally bills each patient, even if another grant or contract covers the costs. · If only one patient is billed (for example, when a family member participates in a patient's counseling
session), count only the billed individual as a patient and count the visit for that one patient. · When a behavioral health provider conducts services via telemedicine, the provider can be credited with a
visit only if the service is documented in the patient's health record. The session will normally be billed to the patient or a third party. · DO NOT count group medical visits.
Location of Services Provided
A visit must take place in health centers' approved service delivery sites (e.g., clinics, schools, homeless shelters, as listed on Form 5B) or in other locations that DO NOT meet HRSA's site criteria but are included in the health center's scope of project (e.g., hospitals, nursing homes, extended care facilities). In addition, virtual visits may occur from other locations. See instructions for Virtual Visits.
Only count one inpatient visit per patient per day, regardless of how many clinic providers see the patient or how often they do so. Other considerations:
· Visits also include encounters with existing hospitalized patients, when health center medical personnel "follow" the patient during the hospital stay as the provider of record or when they provide consultation to the provider of record. This applies when the health center pays their medical personnel and bills the patient either for the specific service or through a global fee.
· When a patient's first encounter is in a hospital, in respite care, or in a similar facility that is not specifically approved in Form 5B as a service delivery site under the scope of the Health Center Program, none of the services for that patient are counted in the UDS.
Counting Multiple Visits by Category of Service
Multiple visits occur when a patient has more than one visit with the health center in a day (in-person and/or virtual).
Count only one visit per patient per service category per provider per location in a single day, regardless of the types or number of services provided or where they occur, as described in the table on the following page.
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Other considerations:
· If multiple medical providers in a single category deliver multiple services to a patient on a single day, count only one visit, even if third-party payers may recognize these as separate billable services. This is typically credited to the provider performing the highest level of or most care, although the health center needs to make this determination for itself.
· Count two visits in a scenario in which services are periodically provided to a patient by two different providers of the same service category type who are located at two different service delivery sites on the same day. This permits patients who are in challenging environments (e.g., in parks or migrant camps) to receive services outside the health center from a licensed or credentialed health center provider and receive services again on the same day at the health center from a different licensed or credentialed provider.
· A virtual visit may count as a separate visit when a patient has another visit on the same day only if the providers are different and the assigned service delivery location of each provider is different.
Maximum Number of Visits per Patient per Day at the Same Service Delivery Site
# of Visits 1 1
1
1 1 for each provider type 1 1 for each provider type
Visit Type Medical Dental
Mental health
Substance use disorder Other professional Vision Enabling
Provider Examples physician, nurse practitioner, physician assistant, certified nurse midwife, nurse dentist, dental hygienist, dental therapist psychiatrist, licensed clinical psychologist, licensed clinical social worker, psychiatric nurse practitioner, other licensed or unlicensed mental health providers alcohol and substance use disorder specialist, psychologist, social worker nutritionist, podiatrist, speech therapist, acupuncturist ophthalmologist, optometrist case manager, health educator
PATIENT
Patients are people who have at least one countable visit during the calendar year. The term "patient" applies to everyone who receives clinic or virtual visits, not just those who receive medical or dental services.
The Universal Report includes all patients who had at least one visit during the calendar year within the scope of project supported by the health center grant or designation.
· Report these patients and their visits on Tables 5 and 6A for each type of service (e.g., medical, dental, enabling) received during the calendar year.
· On the ZIP Code Table, on Tables 3A and 3B, in each section of Tables 4 and 5, and for each service on Table 6A, count each patient once and only once. This applies even if they received more than one service (e.g., medical, dental, enabling) or received services supported by more than one program authority (i.e., section 330(g), section 330(h), section 330(i)).
For each Grant Report, patients reported are those who had at least one countable visit during the calendar year within the scope of project activities supported by the specific section 330 program authority, even if the specific service is not paid for by the grant. The number of patients reported in any cell on the Universal Report includes patients reported in the same cell in the Grant Report.
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Services and Individuals Not Reported on the UDS Report
Some services DO NOT count as a visit for UDS reporting, even though they are critical to the overall provision of care to an individual or a community.
Someone who only receives one of the services described below is not a patient for purposes of UDS reporting.
If an individual receives additional services that require independent professional judgment from a health center provider and the services are documented, they may be considered a patient of the health center.
The following situations are NOT countable visits:
Health screenings or
outreach
Group visits
Tests and other ancillary
services
Dispensing or administering
medications
Health status checks
Services under the Women, Infants, and
Children (WIC) Program
· Do not count screenings (e.g., COVID-19, blood pressure, diabetes) as countable visits, including: · Information sessions for prospective patients; health presentations to community groups;
information presentations about available health services at the center; services conducted at health fairs or schools; immunization drives; services provided to groups, such as dental varnishes or sealants provided at schools; hypertension or diabetes testing; or similar public health efforts that frequently occur as part of community activities that involve conducting outreach or group education.
· Do not count visits conducted in a group setting, except for behavioral health group visits. · The most common non-behavioral health group visits are patient education or health education
classes (e.g., people with diabetes learning about nutrition).
· Do not count services required to perform such tests, such as drawing blood or collecting urine, and other ancillary services, including:
· Laboratory tests (including COVID-19, purified protein derivatives [PPDs], pregnancy, or Hemoglobin A1c [HbA1c].
· Measuring and imaging (including blood pressure, height, weight, sonography, radiology, mammography, retinography, or computerized axial tomography).
· Do not count dispensing medications, including dispensing from a pharmacy or administering medications (such as buprenorphine or warfarin).
· Do not count giving any injection (including for vaccines, COVID-19, allergy shots, or family planning), regardless of education provided at the same time.
· Do not count providing narcotic agonists or antagonists or mixes of these, regardless of whether the patient is assessed at the time of the dispensing and regardless of whether these medications are dispensed regularly.
· Do not count follow-up tests or checks (such as patients returning for HbA1c tests or blood pressure checks).
· Do not count wound care (which is follow-up to the original primary care visit). · Do not count taking health histories. · Do not count making referrals for or following up on external referrals.
· Do not count a person whose only contact with a health center is to receive services (including nutrition) under a WIC program.
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PROVIDER
A provider exercises independent professional judgment in the provision of services rendered to the patient, assumes primary responsibility for assessing the patient, and documents services in the patient's health record.
· Only one provider receives credit for a visit, even when two or more providers are present and participate. · If two or more providers of the same type share the services for a patient, only one provider receives credit for
a visit (see Counting Multiple Visits by Category of Service). · In cases where a preceptor (or attending physician) is following and supervising a licensed resident, the
resident receives credit. (See Appendix B for further instruction on counting interns and residents.) · When health center personnel are following a patient in the hospital, the primary health center personnel in
attendance during the visit is the provider who receives credit for the visit, even if other personnel are present. · Except for physicians and dentists, allocate personnel time by function among the major service categories
based on time dedicated to other positions. · Report physicians according to the specialty in which they are board certified. If a physician has multiple
board certifications, report them according to the specialty in which they are functioning. FTE and visits for physicians with multiple board certifications should be allocated according to the specialty they are practicing. · Appendix A provides a listing of personnel. Only personnel designated as a "provider" can generate visits for purposes of UDS reporting. · Table 5 provides further clarifications to these definitions. See Instructions for Table 5: Staffing and Utilization. · Providers may be personnel of the health center, contracted personnel, or volunteers. · Contracted providers who are paid by the health center with grant funds or program income and who are part of the scope of project, serve center patients, and document their services in the health center's records count as providers. · Contracted providers who are paid for specific visits or services with grant funds or program income and report patient visits to the direct recipient of a BPHC or BHW grant or designation (e.g., under a migrant voucher program or of HCH awardees with sub-awardees) are providers. The direct recipient of the BPHC or BHW grant or designation reports these providers' activities. Since such providers often have no time basis in their report, no FTE would be reported for them if time data were not collected. · Count providers who volunteer to serve patients at the health center's service delivery sites under the supervision of the health center's personnel and document their services and time in the center's records. · Individuals or groups who provide services under formal agreement or contract when the health center does not pay for the visit are not credited as providing a health center visit, unless they are working at an approved service delivery site under the supervision of the appropriate health center personnel and are credentialed by the health center. These providers are generally providing services noted in Column III of the grant scope of project application Form 5A.
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FAQS FOR THE INSTRUCTIONS FOR TABLES
1. What level of documentation is required for emergency, hospital, or respite services? Can we count the visit if the record is incomplete? A patient receiving documented emergency services counts even if some portions of the patient health record are incomplete. Providers who see their established patients at a hospital or respite care facility and make a note in the institutional file can satisfy this criterion by including a summary discharge note showing activities for each of the visit dates.
2. Do we credit the visit to the nurse assisting a physician? No. A nurse assisting a physician during a physical examination by taking vital signs, recording a history, or drawing a blood sample does not receive credit as a separate visit. Eligible medical visits usually involve one of the "Evaluation and Management" billing codes (9920299205 or 9921199215) or one of the health maintenance codes (9938199387, 9939199397).
3. Two different physicians treated the patient at the health center on the same day. Can we count both? No. Only count one visit per service category when care is provided at the same location. For example, only count one medical visit if an obstetrician/gynecologist (OB/GYN) provides prenatal care to a patient at the health center and an internist treats that same patient's hypertension at the same location on the same day. Other examples may include: a family physician and a pediatrician who both see a child or a dental hygienist and a dentist who both see a patient on the same day.
4. How should we count our nurse who splits their 40 hours between medical care and patient education? The nurse who dedicates 20 hours to medical care and 20 hours to providing health education each week would split their 1.0 FTE between medical nurse and health educator.
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Instructions for ZIP Code Data
The ZIP Code Table collects data on patients' geographic origin by primary medical insurance.
There are no major changes to this table.
PATIENTS BY ZIP CODE
· All health centers must report the number of patients served by ZIP code and medical insurance.
· This information enables BPHC to better identify areas served by health centers, potential service area overlaps, and possible areas of unmet need.
· Patients may be mobile during the calendar year; health centers report patients' most recent ZIP code on file.
· This information is to be updated each calendar year.
ZIP Code of Specific Groups
For health centers serving patients without residence information, such as individuals from transient groups, follow the instructions below:
· Report the service location ZIP code as a proxy when a ZIP code location is unavailable or the location offered is questionable.
Patients experiencing homelessness
Patients who are migratory agricultural workers
Patients who are foreign nationals
· If the patient receives services in a mobile health center van and has no other ZIP code, report the ZIP code of the van's location that day.
· Although it is appropriate from a clinical and service delivery perspective to collect the address of a contact person to facilitate communication with the patient; DO NOT use the contact person's address as the patient's address.
· Report the ZIP code of where the patient lived when they received care from the health center. Migratory agricultural workers (as opposed to seasonal workers) may have both a temporary address, where they live when working, as well as a permanent or "downstream" address.
· Report the ZIP code for the location (fixed service delivery site or mobile camp outreach) where patients received services for those whose precise ZIP code is unavailable (e.g., living in cars or on the land).
· Report the current ZIP codes for people from other countries who reside in the United States either permanently or temporarily.
· Report "Other ZIP Code" in cases where patients have a permanent residence outside the country.
Unknown ZIP Code
Report residence in the Unknown category for patients whose residence is not known or for whom a proxy ZIP code is not available.
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Ten or Fewer Patients in ZIP Code
To ease the burden of reporting, combine and report patients from ZIP codes with 10 or fewer patients in the Other category.
INSTRUCTIONS FOR TYPE OF INSURANCE
· Report primary medical insurance for all patients, regardless of the services they receive. This even applies to patients who did not receive medical care.
· Report on patients' origin by their primary medical insurance. · Report children served in school-based health center settings only if they have complete clinic intake forms
that show insurance status and family income. · DO NOT report children as uninsured unless they are receiving minor consent services or their family is
uninsured. · DO NOT report patients as uninsured simply because they are receiving a service that is not covered by health
insurance.
Insurance Categories
Report the patient's primary medical insurance covering medical care, if any, as of the last visit during the calendar year.
Primary medical insurance is the insurance plan that the health center would typically bill first for medical services.
The categories for this table are slightly different from those on Table 4; they combine Medicaid, Children's Health Insurance Program (CHIP), and Other Public into one category. Specific rules guide reporting:
· Report patients who have both Medicare and Medicaid (dually eligible) as Medicare patients, because Medicare is billed before Medicaid. The exception to the Medicare-first rule is the Medicare-enrolled patient who is still working and insured by both an employer-based plan and Medicare. In this case, the principal health insurance is the employer-based plan, which is billed first.
· Report Medicaid and CHIP patients enrolled in a managed care program administered by a private insurance company as Medicaid/CHIP/Other Public.
· Report Medicare administered by a private insurance company as Medicare. · Report the patient by their medical insurance, even if the health center does not bill to the specified insurance. · Report any third-party insurance that patients carry. Section 330 grant awards used to serve special
populations (e.g., MHC, HCH, PHPC) are not a form of medical insurance. · Report patients who are incarcerated as uninsured (whether they were seen in the correctional facility or at the
health center), unless Medicaid or other insurance covers them, and at the ZIP code of the jail or prison. · In instances where patients are in residential drug programs, college dorms, military barracks, etc., report the
patient as living at the ZIP code of the residential program, dorm, or barrack and by their primary medical insurance, not as uninsured. · Report patients whose care is subsidized by state or local government indigent care programs as uninsured.
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· Report patients who received insurance through the Health Insurance Marketplace as Private. · Affordable Care Act subsidies (i.e., cost-sharing premium reductions and premium tax credits) DO NOT
affect insurance categories. Classify patients by their third-party insurer.
FAQS FOR PATIENTS BY ZIP CODE TABLE
1. Do we need to collect information and report on the ZIP code of all our patients? Yes. Although health centers report residence by ZIP code for all patients, some centers may draw patients from many ZIP codes outside of their normal service area. To ease the burden of reporting, consolidate ZIP codes with 10 or fewer patients in the "Other" category.
2. Do we need to collect information and report on the primary medical insurance of all our patients? Yes. Although the ZIP code of a patient may be "unknown," medical insurance information must be obtained for every individual counted as a patient.
3. If a patient did not receive medical care, do we still need their medical insurance information? What about dental patients? Yes. This information is about patients' primary medical insurance resources, not billing. Obtain medical insurance information for all patients, even dental-only patients. For example, if a patient only received case management services, determine if they have primary medical insurance.
4. How do we report patients by insurance when we DO NOT bill that form of insurance? Report the patient by their primary medical insurance, even in those instances that the health center does not or cannot bill to that insurance. Include, for example, patients enrolled in managed care Medicaid but assigned to another primary care provider, or patients with private insurance for which the health center's providers have not been credentialed.
5. How do we report patients by insurance who have their care subsidized by an indigent care program? Report patients as uninsured when their care is subsidized by a state or local government indigent care program. Examples include New Jersey's Uncompensated Care Program, New York's Public Goods Pool Funding, and Colorado's Indigent Care Program.
6. Does the number of patients reported by ZIP code need to equal the total number of unduplicated patients reported on Tables 3A, 3B, and 4? Yes. Several tables and sections must match:
· The total number of patients reported by ZIP code (including "unknown" and "other") on the ZIP Code Table must equal the number of total unduplicated patients reported on Table 3A and sections of Tables 3B and 4.
· The insurance totals reported on the ZIP Code Table must equal insurance reported on Table 4. Specifically:
o The total for ZIP Code Table Column B (Uninsured) must equal Table 4, Line 7, Columns A + B.
o The total for ZIP Code Table Column C (Medicaid/CHIP/Other Public) must equal the sum of Table 4, Line 8, Columns A + B and Line 10, Columns A + B.
o The total for ZIP Code Table Column D (Medicare) must equal Table 4, Line 9, Columns A + B.
o The total for ZIP Code Table Column E (Private) must equal Table 4, Line 11, Columns A + B.
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TABLE: PATIENTS BY ZIP CODE
Calendar Year: January 1, 2021, through December 31, 2021
ZIP Code (a)
[Blank for demonstration]
None/ Uninsured
(b)
[Blank for demonstration]
Medicaid/ CHIP/Other Public
(c)
[Blank for demonstration]
[Blank for demonstration]
[Blank for demonstration]
Other ZIP Codes
Unknown Residence Total
[Blank for demonstration] [Blank for demonstration] [Blank for demonstration]
[Blank for demonstration] [Blank for demonstration] [Blank for demonstration] [Blank for demonstration]
Medicare (d)
[Blank for demonstration] [Blank for demonstration] [Blank for demonstration] [Blank for demonstration]
[Blank for demonstration]
Private (e)
Total Patients (f)
[Blank for demonstration]
[Blank for demonstration]
[Blank for demonstration]
[Blank for demonstration]
[Blank for demonstration]
[Blank for demonstration]
[Blank for demonstration]
[Blank for demonstration]
[Blank for demonstration]
[Blank for demonstration]
Note: The actual online output from the EHBs will display ZIP codes entered by the health center in Column A. Patients by ZIP Code Cross-Table Considerations:
· Patients by ZIP Code and, Tables 3A, 3B, and 4 describe the same patients and the totals must be equal. · The number of patients by insurance source reported on the ZIP Code Table must be consistent with the
number of patients by insurance category reported on Table 4.
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Instructions for Tables 3A and 3B
Tables 3A and 3B collect demographic data (age, sex, race, ethnicity, language, sexual orientation, and gender identity) for patients who accessed services during the calendar year. This information must be collected from patients initially as part of the patient registration or intake process and then must be updated or confirmed annually thereafter.
Table 3A: Patients by Age and by Sex Assigned at Birth
Table 3A provides an unduplicated count of each patient's age and sex assigned at birth. There are no major changes to this table. · Report the number of patients by appropriate categories for age and sex assigned at birth. · Use the individual's age on June 30, 2021. · Report patients according to their sex assigned at birth or sex reported on their birth certificate. · Report date of birth and sex listed on the birth certificate for all patients. There is no "unknown" category on
this table. Note: On the non-prenatal portions of Tables 6B and 7, age is generally defined as the patient's age as of January 1, 2021, except where noted. Thus, the numbers on Table 3A will not be the same as those on Tables 6B and 7 even if all the patients at a health center were medical patients, though they will usually be similar.
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Table 3B: Demographic Characteristics
Table 3B provides an unduplicated count of patients by demographic characteristics.
There are no major changes to this table.
· Report the number of patients by their self-identified race, ethnicity, language preference, sexual orientation, and gender identity.
PATIENTS BY HISPANIC OR LATINO/A ETHNICITY AND RACE (LINES 18)
Table 3B displays the race and ethnicity (i.e., Hispanic or Latino/a) of the patient population in a matrix format. This allows for the reporting on the racial and ethnic identification of all patients.
Hispanic or Latino/a Ethnicity
Table 3B collects information on whether or not patients consider themselves to be of Hispanic or Latino/a ethnicity, regardless of their race.
Column A (Hispanic or Latino/a)
Column B (Non-Hispanic or Latino/a)
· Report the number of patients of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, broken out by their racial identification. Include in this count Hispanic or Latino/a patients born in the United States.
· Report patients who self-report as being of Hispanic or Latino/a ethnicity but DO NOT separately select a race on Line 7, "Unreported/Refused to Report" race. Health centers should not default these patients to any other category.
· Report the number of patients who indicate that they are not Hispanic or Latino/a.
· If a patient self-reported a race but has not made a selection for the Hispanic/non-Hispanic or Latino/a question, presume that the patient is not Hispanic or Latino/a.
Column C (Unreported/Refused to Report
Ethnicity)
· Report on Line 7 only those patients who left the entire race and Hispanic or Latino/a ethnicity part of the intake form blank or those who indicated that they refuse to report this data. Only one cell is available in this column.
· DO NOT count patients from Portugal, Brazil, or Haiti whose ethnicity is not otherwise tied to the Spanish language.
Race
All patients must be classified in one of the racial categories.
· Report patients in one of eight race categories: Asian, Native Hawaiian, Other Pacific Islander, Black/African American, American Indian/Alaska Native, White, More than one race, or Unreported/Refused to report race.
· Report patients who self-report their race but DO NOT indicate if they are Hispanic or Latino/a in Column B as not Hispanic or Latino/a on the appropriate race line.
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· Patients sometimes categorized as "Asian/Other Pacific Islander" in other systems are reported on the UDS in one of three distinct categories:
o Line 1, Asian: Patients having origins in any of the original peoples of Asia, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, India, Indonesia, Thailand, or Vietnam
o Line 2a, Native Hawaiian: Patients having origins to any of the original peoples of Hawai'i o Line 2b, Other Pacific Islander: Patients having origins in any of the original peoples of Guam, Samoa,
Tonga, Palau, Chuuk, Yap, Saipan, Kosrae, Ebeye, Pohnpei or other Pacific Islands in Micronesia, Melanesia, or Polynesia
· Line 4, American Indian/Alaska Native: Patients who trace their origins to any of the original peoples of North, South, and Central America and who maintain tribal affiliation or community attachment
· Line 6, More than one race: Use this line only if your system captures multiple races (but not a race and an ethnicity) and the patient has chosen two or more races. This is usually done with an intake form that lists the races and tells the patient to "check one or more" or "check all that apply." "More than one race" must not appear as a selection option on your intake form.
o DO NOT use "More than one race" for Hispanic or Latino/a people who DO NOT select a race. Report these patients on Line 7 (Unreported/Refused to Report), as noted above.
PATIENTS BEST SERVED IN A LANGUAGE OTHER THAN ENGLISH (LINE 12)
This section of Table 3B identifies the patients who have linguistic barriers to care.
· Report on Line 12 the number of patients who are best served in a language other than English, including those who are best served in sign language.
· Include those patients who were served in a second language by a bilingual provider and those who may have brought their own interpreter.
· Include patients residing in areas where a language other than English is the dominant language, such as Puerto Rico or the Pacific Islands.
Note: Data reported on Line 12, Patients Best Served in a Language Other than English, may be estimated if the health center does not maintain actual data in its HIT. If an estimate is required, the estimate should be based on a sample where possible; indicate this on the Table 3B, Table Comments. This is the only place on the UDS where an estimate is accepted.
PATIENTS BY SEXUAL ORIENTATION (LINES 1319)
Sexual orientation is how an individual describes their emotional and sexual attraction to others.
Health centers are encouraged to establish routine data collection systems to support patient-centered, high-quality care for patients of all sexual orientations. As with all demographic data, this information is self-reported by patients (or by their caregivers if the patient cannot answer the questions themselves).
Collection of sexual orientation data from patients younger than 18 years of age is not mandated, but the opportunity to report this information must be provided to all patients regardless of age.
Furthermore, patients have the choice not to disclose their sexual orientation. When sexual orientation information is not collected or this section of the registration form is left blank, report the patient on Table 3B as "Unknown" on Line 18a. Patients may change how they identify themselves over time. The following descriptions may assist with data collection.
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· Line 13, Lesbian or Gay: Report patients who are emotionally and sexually attracted to people of their own gender.
· Line 14, Heterosexual (or straight): Report patients who are emotionally and sexually attracted to people of a different gender.
· Line 15, Bisexual: Report patients who are emotionally and sexually attracted to people of their own gender and people of other genders.
· Line 16, Something else: Report patients who identify themselves as queer, asexual, pansexual, or another sexual orientation not captured in Lines 1315 above or Lines 1718a below.
· Line 17, Don't know: Report patients who self-report that they DO NOT know their sexual orientation. · Line 18, Chose not to disclose: Report patients who chose not to disclose their sexual orientation. · Line 18a, Unknown: Report patients for whom the health center does not know the sexual orientation (i.e.,
the health center did not implement systems to permit patients to state their sexual orientation or the patient left this section blank). · Line 19, Total Patients: Sum of Lines 13 through 18a.
PATIENTS BY GENDER IDENTITY (LINES 2026)
Gender identity is the internal sense of gender. An individual may be male, female, a combination of male and female, or another gender that may not be congruent with a patient's sex assigned at birth.
This section helps to characterize populations served by health centers. Note that the gender identity reported on Table 3B is the patient's current gender identity. A patient's sex assigned at birth is reported on Table 3A.
As with all demographic data, this information is self-reported by patients (or by their caregivers if the patient cannot answer the questions themselves). Collection of gender identity data from patients younger than 18 years of age is not mandated, but the opportunity to provide this information must be provided to all patients regardless of age.
Furthermore, patients have the choice not to disclose their gender identity. When gender identity information is not collected or this section of the registration form is left blank, report the patient on Table 3B as "Unknown" on Line 25a. Report sex assigned at birth on Table 3A. DO NOT use sex assigned at birth to identify the gender of patients. The following descriptions may assist with data collection, but it is important to note that terminology is evolving and patients may change how they identify themselves over time.
· Line 20, Male: Report patients who identify themselves as a man/male. · Line 21, Female: Report patients who identify themselves as a woman/female. · Line 22, Transgender Man/Transgender Male/Transgender Masculine: Report transgender patients who
describe their gender identity as man/male. (Some may just use the term "man"). · Line 23, Transgender Woman/Transgender Female/Transgender Feminine: Report transgender patients
who describe their gender identity as woman/female. (Some may just use the term "woman"). · Line 24, Other: Report patients who DO NOT think that one of the four categories above adequately
describes them. Include patients who identify themselves as genderqueer or non-binary. · Line 25, Chose not to disclose: Report patients who chose not to disclose their gender.
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· Line 25a, Unknown: Report patients for whom the health center does not know the gender identity (i.e., the health center did not implement systems to permit patients to state their gender identity or the patient left this section blank).
· Line 26, Total Patients: Sum of Lines 20 through 25a.
FAQS FOR TABLES 3A AND 3B
1. Our health center collects more robust race and ethnicity data than required by the UDS. Why is the data limited? The UDS classifications are consistent with those used by the Census Bureau and HHS as per the October 2011 guidance titled "U.S. Department of Health and Human Services Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status" issued by OMB. These standards govern the categories used to collect and present federal data on race and ethnicity. OMB requires a minimum of five categories (White, Black or African American, American Indian or Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander) for race. In addition to the five race groups, OMB states that respondents should be offered the option of selecting more than one race. Line 6 permits reporting of those people who have chosen to report two or more races.
2. Do we have to report the race and Hispanic or Latino/a ethnicity of all our patients? Yes. The UDS requires the classification of race and Hispanic or Latino/a ethnicity information to assess health disparities across sub-populations. Health centers whose data systems DO NOT support such reporting must enhance their systems to permit the required level of reporting, rather than using the "unreported/refused to report" categories.
3. How are patients of Hispanic or Latino/a ethnicity reported? Race and ethnicity data appear in a matrix on Table 3B. Patients who in other systems might be reported as Hispanic or Latino/a independent of race are reported in Column A of Table 3B of the UDS as Hispanic or Latino/a and reported on Lines 17 based on their race. If Hispanic or Latino/a is the only identification recorded in the center's patient files, report these patients in Column A on Line 7 as having an "unreported" racial identification, and update your data system to permit the collection of both race and ethnicity.
4. Can we have a choice on our registration form of "more than one race"? No. To count patients as being of "more than one race," they must have the option of checking two or more boxes under race and must have indeed checked more than one.
5. How are patients who receive different types of services or use more than one of our health center's service delivery sites reported? For example, how do we report a patient who receives both medical and dental services or a patient who receives primary care from one service delivery site but gets prenatal care at another? The ZIP Code Table and Tables 3A, 3B, and 4 each provide an unduplicated patient count. Count each individual who has at least one visit reported on Table 5 only once on the ZIP Code Table and, Tables 3A, 3B, and 4, regardless of the type or number of services they receive or where they receive them. We define visits in detail in the Instructions for Tables that Report Visits, Patients, and Providers section. Note the following:
· DO NOT count individuals who receive WIC services and no other services at the health center as patients on Table 3A or 3B (or anywhere in the UDS).
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· DO NOT count individuals who only receive imaging or lab services or whose only service was an immunization or screening test as patients on Table 3A or 3B (or anywhere in the UDS).
· DO NOT count individuals who only receive health status checks and health screenings as patients on Table 3A or 3B (or anywhere in the UDS).
6. Should the numbers on Tables 3A and 3B tie to UDS data reported on other tables? Yes. The sum of Table 3A, Line 39, Columns A and B (total patients by age and by sex assigned at birth) must equal: · Total Patients by ZIP Code; · Table 3B, Line 8, Column D (total patients by Hispanic or Latino/a ethnicity and race); · Table 3B, Line 19 (total patients by sexual orientation); · Table 3B, Line 26 (total patients by gender identity); · Table 4, Line 6 (total patients by income); and · Table 4, Line 12, Columns A and B (total patients by insurance status). The sum of Table 3A, Lines 118, Columns A and B (total patients age 017 years) must equal: · Table 4, Line 12, Column A (total patients age 017 years). The sum of Table 3A, Lines 1938, Columns A and B (total patients age 18 and older) must equal: · Table 4, Line 12, Column B (total patients age 18 and older).
7. I have multiple, separate data systems. How do I include their data on these tables? It is the health center's responsibility to ensure there is no duplication of data. Count patients only once, regardless of the number of different types of services they receive. This may require the downloading and merging of data from each system to eliminate duplicates or checking them manually. This can be a timeconsuming and potentially expensive process and should start as soon as the year ends to ensure sufficient time for completion prior to the submission due date.
8. What do we do if we did not collect sexual orientation and/or gender identity elements? All health centers are required to include these data elements in the registration or intake forms or during the visit. If you did not implement the gathering of sexual orientation and/or gender identity data, report patients on Table 3B as "Unknown" on Line 18a, sexual orientation, and Line 25a, gender identity. DO NOT use sex at birth reported on Table 3A to complete gender identity on Table 3B.
32 2021 UDS MANUAL | Instructions for Tables 3A and 3B
UDS SUPPORT CENTER, 866-UDS-HELP, UDSHELP330@BPHCDATA.NET 9. Does the UDS require health care providers to ask minors for sexual orientation and gender identity
data? The collection of sexual orientation and gender identity data is not required for minors. The information should be included in the system and in the corresponding lines if a patient chooses to self-report their sexual orientation and gender identity. If this information is unavailable for minors, report the patient on the Unknown lines (18a and 25a). 10. Will parents be able to access their child's response to a UDS sexual orientation and gender identity inquiry? There are specific provisions about protecting confidentiality of minors for patient visits related to sexual health. Generally, there are "minor consent" laws that permit treatment to be provided to and data collected from minors without their parent's knowledge or approval. Contact your state Primary Care Association for state-specific rules and regulations. 11. How are the categories for sexual orientation and gender identity defined? The UDS classifications are based on the guidance provided in the 2015 Edition Health Information Technology (Health IT) Certification Criteria, 2015 Edition Base Electronic Health Record (EHR) Definition, and ONC Health IT Certification Program Modifications.
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TABLE 3A: PATIENTS BY AGE AND BY SEX ASSIGNED AT BIRTH
Calendar Year: January 1, 2021, through December 31, 2021
Line
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39
Age Groups
Under age 1 Age 1 Age 2 Age 3 Age 4 Age 5 Age 6 Age 7 Age 8 Age 9 Age 10 Age 11 Age 12 Age 13 Age 14 Age 15 Age 16 Age 17 Age 18 Age 19 Age 20 Age 21 Age 22 Age 23 Age 24 Ages 2529 Ages 3034 Ages 3539 Ages 4044 Ages 4549 Ages 5054 Ages 5559 Ages 6064 Ages 6569 Ages 7074 Ages 7579 Ages 8084 Age 85 and over
Total Patients (Sum of Lines 138)
Male Patients (a)
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Female Patients (b)
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
Note: Table 3A Cross-Table Considerations:
· Table 3A, Line 39 = Table 3B, Line 8 Column D = Table 3B, Lines 19 and 26 = Total Patients by ZIP Code = Table 4, Lines 6 and 12.
· If you submit Grant Reports, the total number of patients reported on the grant table must be less than or
equal to the corresponding number on the Universal Report for each cell.
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TABLE 3B: DEMOGRAPHIC CHARACTERISTICS
Calendar Year: January 1, 2021, through December 31, 2021
blank
Line
1 2a 2b
2
3 4 5 6 7 8
Patients by Race and Hispanic or Latino/a Ethnicity
blank
Patients by Race
Hispanic or Latino/a (a)
Asian Native Hawaiian Other Pacific Islander Total Native Hawaiian/Other Pacific Islander (Sum Lines 2a + 2b) Black/African American American Indian/Alaska Native White More than one race Unreported/Refused to report race
Total Patients (Sum of Lines 1 + 2 + 3 to 7)
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
blank
NonHispanic or
Latino/a (b)
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
blank
Unreported/Refused to Report Ethnicity
(c)
<cell not reported> <cell not reported> <cell not reported> <cell not reported>
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
<cell not reported> <cell not reported> <cell not reported> <cell not reported> <blank for demonstration> <blank for demonstration>
blank Total
(d) (Sum Columns
a+b+c)
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
Line Patients Best Served in a Language Other than English
12
Patients Best Served in a Language Other than English
Number (a)
<blank for demonstration>
Line Patients by Sexual Orientation
divider
Number (a)
Line
Patients by Gender Identity
Number (a)
13 Lesbian or Gay 14 Heterosexual (or straight) 15 Bisexual
<blank > <blank > <blank >
16 Something else
<blank >
17 Don't know
<blank >
18 Chose not to disclose
<blank >
18a Unknown
<blank >
19
Total Patients <blank >
(Sum of Lines 13 to 18a)
divider
20
Male
<blank>
divider
21
divider
22
divider
23
divider
24
Female
Transgender Man/Transgender Male/Transgender Masculine Transgender Woman/Transgender Female/Transgender Feminine
Other
<blank > <blank > <blank > <blank >
divider
25
Chose not to disclose
<blank >
25a Unknown
<blank >
divider
26
Total Patients <blank>
(Sum of Lines 20 to 25a)
Note: Table 3B Cross-Table Considerations:
· Table 3B, Lines 8, 19, and 26 = Table 3A, Line 39 = Total Patients by ZIP Code = Table 4, Lines 6 and 12 · Tables 3B and 7 both report patients by race and Hispanic or Latino/a ethnicity. The data sources for
identifying race and ethnicity for the two tables are the same, and the number of patients reported on Table 7 by race and ethnicity cannot exceed the number of patients in the same category on Table 3B. · If you submit Grant Reports, the total number of patients reported on the grant table must be less than or equal to the corresponding number on the Universal Report for each cell.
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Instructions for Table 4: Selected Patient Characteristics
Table 4 collects descriptive data on selected characteristics of health center patients.
There are no major changes to this table.
INCOME AS A PERCENT OF POVERTY GUIDELINE, LINES 16
The report should include the most current income data for all patients (not only from patients applying for a sliding fee discount), which must have been collected at or within 12 months prior to the most recent calendar year visit.
Determine a patient's income relative to the 2021 federal poverty guidelines (FPG).
· Report patients by income, as defined by the health center's board policy consistent with the Health Center Program Compliance Manual. Children, with the exception of emancipated minors or those presenting for minor consent services, should be classified under their parents' income.
· Report patients whose information was not collected within one year of their last visit in the calendar year on Line 5 as "Unknown."
· Self-declaration of income from patients may be acceptable if it is consistent with the health center's boardapproved policies and procedures. This is particularly important for those patients whose wages are paid in cash and who have no other means of proving their income. If income information consistent with the health center's board policy is lacking, report the patient as having "Unknown" income.
· DO NOT allocate patients with "Unknown" income to income groups. · DO NOT classify a patient who is experiencing homelessness, is a migratory agricultural worker, or is on
Medicaid as having income below the FPG based on these factors alone.
PRINCIPAL THIRD-PARTY MEDICAL INSURANCE, LINES 712
This portion of the table provides data on patients classified by their age and primary source of insurance for medical care. DO NOT report other forms of insurance, such as dental, mental health, or vision coverage. Note that there is no "unknown" insurance classification on this table, and that states often rename federal insurance programs, such as CHIP and Medicaid. HRSA requires that health centers collect medical insurance information each calendar year from all patients to maximize third-party payments.
· Patient primary medical insurance is classified into seven types, as shown on the following pages. · In rare instances, a patient may have insurance that the health center cannot or does not bill. Even in these
instances, report the patient as being insured and report the type of insurance. · Report the primary medical insurance patients had at the time of their last visit regardless of whether that
insurance was billed or paid for any or all of the visit services. · Patients are divided into two age groups: 017 (Column A) and 18 and older (Column B) based on their age
on June 30, 2021 (consistent with ages reported on Table 3A). · DO NOT report public programs that reimburse for selected services, such as the Early and Periodic
Screening, Diagnosis, and Treatment (EPSDT) program; Breast and Cervical Cancer Control Program (BCCCP); or Title X, as a patient's primary medical insurance. Note: However, report the revenue from public programs that reimburse for selected services as Other Public payers on Table 9D.
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None/Uninsured (Line 7)
Report patients who did not have medical insurance at the time of their last visit on Line 7. This may include patients who were insured earlier in the year or patients whose visit was paid for by a third-party source that was not insurance, such as EPSDT, BCCCP, Title X, or some state or local safety net or indigent care programs.
· Report a minor receiving services with parental consent under the family's insurance.
· Report children seen in a school-based program under their parent's health insurance. This information must be obtained if they are to be included in the UDS Report. Report emancipated minors or patients seeking minor-consent services permitted in the state, such as family planning or mental health services, as Uninsured if they DO NOT have access to the parent's information.
· Presume a patient with Medicaid, Private, or Other Public dental insurance to have the same kind of medical insurance. If a patient does not have dental insurance, you may not assume that they are uninsured for medical care. Instead, obtain this information from the patient.
· Patients served in correctional facilities may be classified as Uninsured. If patients in correctional facilities have documentation of insurance, such as Medicaid or Medicare, then report them on that insurance line.
· Obtain the coverage information of patients in facilities (other than correctional), such as residential drug programs, college dorms, and military barracks. DO NOT assume them to be uninsured.
· DO NOT report patients as Uninsured if they have medical insurance that did not pay for their visit.
Medicaid (Line 8a)
Report patients covered by state-run programs operating under the guidelines of Titles XIX and XXI (as appropriate) of the Social Security Act.
· Include Medicaid programs known by state-specific names (e.g., California's "Medi-Cal" program).
· Include patients covered by "state-only" programs covering individuals who are ineligible for federal matching funds (e.g., undocumented children, pregnant patients) and paid through Medicaid.
· Report patients enrolled in both Medicaid and Medicare on Lines 9 (Medicare) and 9a (Dually Eligible), but not on Line 8a.
· Report patients who are enrolled in Medicaid but receive services through a private managed care plan that contracts with the state Medicaid agency on Line 8a, not as privately insured (Line 11). This also applies in states that have a Medicaid waiver permitting Medicaid funds to be used to purchase private insurance for services.
CHIP-Medicaid (Line 8b)
Report patients covered by the Children's Health Insurance Program (CHIP) Reauthorization Act and provided through the state's Medicaid program.
· In states that use Medicaid to handle the CHIP program, it is sometimes difficult or impossible to distinguish between "Medicaid" and "CHIP-Medicaid." In other states, the distinction is readily apparent (e.g., they have different cards). Even where it is not obvious, CHIP patients may still be identifiable from a "plan" code or some other embedded code in the membership number. This may also vary from county to county within a state. Obtain information on coding practice from the state and/or county.
· If there is no way to distinguish between Medicaid and CHIP administered through Medicaid, classify all covered patients as Medicaid (Line 8a).
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Medicare (Line 9)
Report patients covered by the federal insurance program for the aged, blind, and disabled (Title XVIII of the Social Security Act).
· Report patients who have Medicare and Medicaid ("dually eligible") on Line 9. In addition, report as Dually Eligible on Line 9a.
· Report patients who have Medicare and a private ("Medigap") insurance on Line 9. DO NOT include them as Dually Eligible on Line 9a.
· Report patients enrolled in "Medicare Advantage" products on Line 9, even though their services were covered by a private insurance company.
· Report Medicare-enrolled patients who are still working and are insured by both an employer-based plan and Medicare as Private Insurance on Line 11, because the employer-based insurance plan is billed first. DO NOT include them as Dually Eligible on Line 9a.
Dually Eligible (Medicare and Medicaid) (Line 9a)
Report patients with both Medicare and Medicaid insurance.
· Report patients who are dually eligible on Line 9a and include them on Line 9. This line is a subset of Line 9 (Medicare).
· DO NOT include Medigap (supplemental insurance plan) enrollees on Line 9a. Report them only on Line 9.
Other Public Insurance (Non-CHIP) (Line 10a)
Report state and/or local government programs, such as Massachusetts' CommonHealth plan, that provide a broad set of benefits for eligible individuals. Include any public-paid or subsidized private insurance not reported elsewhere on Table 4.
· Report Medicaid expansion programs using Medicaid funds to help patients purchase their insurance through exchanges as Medicaid (Line 8a) if it is possible to identify them. Otherwise, report them as Private Insurance (Line 11).
· DO NOT report any CHIP, Medicaid, or Medicare patients on Line 10a. · DO NOT report uninsured individuals whose visit may be covered by a public source with limited benefits,
such as Title X, EPSDT, BCCCP, AIDS Drug Assistance Program providing pharmaceutical coverage for HIV patients, etc. Note: Public programs that reimburse for selected services are, however, considered Other Public payers on Table 9D. · DO NOT include patients covered by workers' compensation (which is liability insurance for the employer-- not health insurance for the patient). · DO NOT include patients who have insurance through federal or state insurance exchanges, regardless of the extent to which their premium cost is subsidized (in whole or in part). Report them as Private Insurance (Line 11).
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Other Public Insurance CHIP (Line 10b)
In states where CHIP is contracted through a private third-party payer, report patients on the Other Public Insurance CHIP line.
· Report CHIP programs that are run through the private sector, often administered through health maintenance organizations (HMOs). Coverage may appear to be a private insurance plan (such as Blue Cross/Blue Shield) but is funded through CHIP and is to be counted on Line 10b.
· Report CHIP patients who are on plans administered by Medicaid coordinated care organizations (CCOs). · DO NOT report CHIP as Private Insurance.
Private Insurance (Line 11)
Report patients with health insurance provided by private (commercial) and not-for-profit companies.
· Individuals may obtain insurance through employers or on their own. · Include patients who purchase insurance through the federal or state exchanges. · In states using Medicaid expansion to support the purchase of insurance through exchanges, report patients
covered under these plans on Line 8a (Medicaid). Report patients who are not identifiable as Medicaid patients on Line 11 (Private Insurance). · Private insurance includes insurance purchased for public employees or retirees, such as Tricare, Trigon, or the Federal Employees Benefits Program.
MANAGED CARE UTILIZATION, LINES 13A13C
This part of Table 4 provides data on managed care enrollment during the calendar year and specifically reports on patient member months in health center contracted comprehensive medical managed care plans.
· If patients are enrolled in a managed care program that permits them to receive care from any number of providers, including providers other than the health center and its providers, this is not to be reported as managed care in the UDS, and no member months are reported in this situation.
· DO NOT report in this section enrollees in primary care case management (PCCM) programs, the Centers for Medicare & Medicaid Services (CMS) patient-centered medical home (PCMH) demonstration grants, or other third-party plans that pay a monthly fee (often as low as $5 to $10 per member per month) to "manage" patient care.
· DO NOT include managed care enrollees whose capitation or enrollment is limited to behavioral health or dental services only. (However, an enrollee who has medical and dental is counted).
Member Months
A member month is defined as one individual enrolled in a managed care plan for one month. For example, an individual who is a member of a plan for a full year generates 12 member months; a family of five enrolled for six months generates 30 member months (5 individuals × 6 months = 30 member months).
Member month information is most often obtained from monthly enrollment lists generally supplied by managed care companies to their providers. Health centers should always save these documents. In the event they have not been saved, health centers should request duplicates early to permit timely filing of the UDS Report.
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Note: It is possible for an individual to be enrolled in a managed care plan, assigned to a health center, and yet not be seen during the calendar year. The member months for such individuals are still to be reported in this section. This is the only place on the UDS tables where an individual may be reported who is not being counted as a patient.
Capitated Member Months (Line 13a)
Report the total capitated member months by source of payment. This is derived by adding the total enrollment reported from each capitated plan for each month.
· A patient is in a capitated plan if the contract between the health center and the HMO, accountable care organization (ACO), or other similar plan stipulates that, for a flat payment per month, the health center will provide the patient all the services on a negotiated list. (Oregon programs should include enrollees in CCOs on this line).
· This usually includes, at a minimum, all medical office visits. · Payments are received (and reported on Table 9D) regardless of whether any service is rendered to the patient
in that month. The capitated member months reported on Line 13a relate to the net capitated revenue reported on Table 9D, Lines 2a, 5a, 8a, and/or 11a. Fee-for-Service Member Months (Line 13b)
Report the total fee-for-service member months by source of payment.
· A fee-for-service member month is defined as one patient being assigned to a health center or health center service delivery provider for one month, during which time the patient may receive contractually defined basic primary care services only from the health center but for whom the services are paid on a fee-for-service basis.
· There is a relationship between the fee-for-service member months reported on Line 13b and the revenue reported on Table 9D on Lines 2b, 5b, 8b, and/or 11b.
· It is common for patients to have their primary care covered by capitation but other services (e.g., behavioral health or pharmacy) paid separately on a fee-for-service basis as a "carve-out" in addition to the capitation.
· DO NOT include member months for individuals who receive "carved-out" services under a fee-for-service arrangement on Line 13b if those individuals have already been counted for the same month as a capitated member on Line 13a.
SPECIAL POPULATIONS, LINES 1426
This section asks for a count of patients from special populations, including migratory and seasonal agricultural workers and their family members, patients who are experiencing homelessness, patients who are served by school-based health centers, patients who are veterans, and patients served at a health center located in or immediately accessible to a public housing site. Awardees who receive funding from section 330(g) (MHC) and section 330(h) (HCH) must provide additional information on their agricultural employment and/or housing characteristics.
· All health centers report these populations, regardless of whether they directly receive special population funding.
· Migratory or seasonal agricultural workers' status must be verified at least every 2 years by MHC awardees.
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· Housing status must be collected by HCH awardees at the first visit of the year when the patient was identified to be experiencing homelessness.
· The special populations detailed below are not mutually exclusive. Patients can be reported in more than one category, as appropriate (e.g., a patient can be reported as both a veteran and experiencing homelessness).
Total Migratory and Seasonal Agricultural Workers and Their Family Members, Lines 1416
Total Agricultural Workers or Dependents, Line 16: Report the number of patients seen during the calendar year who were either migratory or seasonal agricultural workers, dependent family members of migratory or seasonal agricultural workers, or aged or disabled former migratory agricultural workers (as described in the statute section 330(g)(1)(B)). All health centers must report on this line.
Only health centers that receive section 330(g) (MHC) funding provide separate totals for migratory and seasonal agricultural workers on Lines 14 and 15. For section 330(g) awardees, the sum of Lines 14 + 15 = Line 16.
· For either migratory or seasonal agricultural workers, report patients who meet the definition of agriculture as farming in all its branches, as defined by the Office of Management and Budget (OMB)-developed North American Industry Classification System (NAICS), and include seasonal workers included in codes 111 and 112 and all sub-codes therein, including sub-codes 1151 and 1152.
Instructions for reporting migratory and seasonal agricultural workers:
· Migratory Agricultural Workers, Line 14: Report patients whose principal employment is in agriculture and who establish a temporary home for the purposes of such employment as a migratory agricultural worker, as defined by section 330(g) of the PHS Act. Migratory agricultural workers are usually hired laborers who are paid piecework, hourly, or daily wages. Include patients who had such work as their principal employment within 24 months of their last visit, as well as their dependent family members who have also used the center. The family members may or may not move with the worker or establish a temporary home.
Note: Agricultural workers who leave a community to work elsewhere are classified as migratory workers when served in their home community, as are those who migrate to a community to work there.
o Include aged and disabled former migratory agricultural workers, as defined in section 330(g)(1)(B), and their family members. Aged and disabled former agricultural workers include those who were previously migratory agricultural workers but who no longer work in agriculture because of age or disability.
· Seasonal Agricultural Workers, Line 15: Report patients whose principal employment is in agriculture on a seasonal basis (e.g., picking fruit during the limited months of a picking season), but who DO NOT establish a temporary home for purposes of such employment. Seasonal agricultural workers are usually hired laborers who are paid piecework, hourly, or daily wages. Include patients who have been so employed within 24 months of their last visit, as well as their dependent family members who are patients of the health center.
Note: Seasonal agricultural workers may be employed throughout the year for multiple crop seasons and as a result might work full-time.
Total Homeless Patients, Lines 1723
Total Homeless, Line 23: Report the total number of patients known to have experienced homelessness at the time of any service provided during the calendar year, even if their housing situation changes during the year. All health centers must report on this line.
Only health centers receiving section 330(h) (HCH) funding provide separate totals for patients by housing location on Lines 1722. For section 330(h) awardees, the sum of Lines 17 through 22 = Line 23.
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· Report patients who lack housing (without regard to whether the individual is a member of a family). Include patients whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations. Include patients who reside in transitional housing or permanent supportive housing.
· Children and youth at risk of homelessness, homeless veterans, and veterans at risk of homelessness may be included.7
HCH awardees will provide detail on patients experiencing homelessness by the type of shelter arrangement the patients had when they were first encountered for a visit during the calendar year while experiencing homelessness. The following applies when categorizing patients for Lines 17 through 22:
· Report the patient's shelter arrangement as of the first visit during the calendar year when the patient was experiencing homelessness. The shelter arrangement is reported as where the patient was housed the prior night.
· Report patients who spent the prior night incarcerated, in an institutional treatment program (e.g., mental health, substance use disorder), or in a hospital based on where they intend to spend the night after their visit/release. If they DO NOT know, report their shelter arrangement as Street, on Line 20.
· Shelter, Line 17: Report patients who are living in an organized shelter for individuals experiencing homelessness. Shelters that generally provide meals and a place to sleep are regarded as temporary and often limit the number of days or the hours of the day that a resident may stay at the shelter.
· Transitional Housing, Line 18: Transitional housing units are generally small units (six people is common) where people transition from a shelter and are provided extended, but temporary, housing stays (generally between 6 months and 2 years) in a service-rich environment. Transitional housing provides a greater level of independence than traditional shelters and may require the resident to pay some or all of the rent, participate in the maintenance of the facility, and/or cook their own meals. Count only those patients who are transitioning from a homeless environment. DO NOT include those who are transitioning from jail or those residing in or transitioning from an institutional treatment program, the military, schools, or other institutions.
· Doubled Up, Line 19: Report patients who are living with others. The arrangement is considered to be temporary and unstable, though a patient may live in a succession of such arrangements over a protracted period. DO NOT count the individual who invites a patient experiencing homelessness to stay in their home for the night.
· Street, Line 20: Report in this category patients who are living outdoors, in a vehicle, in an encampment, in makeshift housing/shelter, or in other places generally not deemed safe or fit for human occupancy.
· Permanent Supportive Housing,8 Line 21a: Report patients who are in permanent supportive housing in this category. Permanent supportive housing usually is in service-rich environments, does not have time limits, and may be restricted to people with some type of disabling condition.
· Other, Line 21: Report patients who were housed when first seen during the year but who were still eligible for the program because they experienced homelessness during the previous 12 months. HCH-funded programs may continue to serve patients who no longer experience homelessness due to becoming residents of permanent housing for 12 months after their last visit as homeless. Include them in this category. Also include patients who reside in single-room-occupancy (SRO) hotels or motels and patients who reside in other day-to-day paid housing or other housing programs that are targeted to homeless populations.
7 Health centers may use criteria as defined by the U.S. Department of Housing and Urban Development (HUD) to assist in defining "children and youth at risk of homelessness, homeless veterans, and veterans at risk of homelessness." 8 Health centers may use criteria as defined by HUD to assist in defining permanent supportive housing.
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· Unknown, Line 22: Report patients known to be experiencing homelessness whose housing arrangements are unknown.
· DO NOT report patients currently residing in a jail or an institutional treatment program as homeless until they are released to the street with no housing arrangement.
· DO NOT report patients who are part of the foster system program and are placed with a family, group home, or in some other arrangement as homeless.
Total School-Based Health Center Patients, Line 24
All health centers that identified a school-based health center as a service delivery site in their scope of project (as documented on Form 5B) are to report the total number of patients who received primary health care services at the approved school service delivery site(s).
· Report patients served at in-scope school-based health centers located on or near school grounds, limited to preschool, kindergarten, and primary through secondary schools, that provide on-site comprehensive preventive and primary health services.
· Services are targeted to the students at the school but may also be provided to siblings or parents and may occasionally include patients residing in the immediate vicinity of the school.
· DO NOT include as patients students who only receive screening services or mass treatment, such as vaccinations or fluoride treatments, at a school.
Total Veterans, Line 25
All health centers are to report the total number of patients who served in the active military, naval, or air service, which includes full-time service in the Air Force, Army, Coast Guard, Marines, Navy, Space Force, or as a commissioned officer of the Public Health Service or National Oceanic and Atmospheric Administration. In addition, include patients who served in the National Guard or Reserves on active duty status.
Include this information in the patient information/intake form at each center.
· Report only those who were discharged or released under conditions other than dishonorable. · Report only those who affirmatively indicate they previously served in these branches of the military or
armed forces. · DO NOT report patients who do not respond, regardless of other indicators. · DO NOT report veterans of other nations' militaries, even if they served in wars in which the United States
was also involved.
Total Patients Served at a Health Center Service Delivery Site Located in or Immediately Accessible to a Public Housing Site, Line 26
All health centers are to report all patients seen at a service delivery site located in or immediately accessible to public housing, regardless of whether the patients are residents of public housing or the health center receives funding under section 330(i) PHPC.
· Report patients on this line if they are served at health center service delivery sites that meet the statutory definition for the PHPC program (located in or immediately accessible to public housing).
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· Report all patients seen at the health center service delivery site if it is located in or immediately accessible to agency-developed, -owned, or -assisted low-income housing, including mixed-finance projects.
· This is the only field in the UDS Report that requires you to provide a count of all patients based on the health center service delivery site's proximity to public housing.
· DO NOT include Section 8 housing units that receive no public housing agency support other than Section 8 housing vouchers. Note: Not all patients served at service delivery sites located in or immediately accessible to public housing are themselves residents of public housing, but they are to be included in the count.
FAQS FOR TABLE 4
1. Do we determine a patient's income relative to the FPG based on the location of the health center or based on the residence of the patient? Use the FPG based on the location of the health center. All states (except Alaska and Hawaii) and the U.S. territories use the standard poverty guidelines. For patients being served in Alaska or Hawaii, use the FPG established for those locations.
2. Patients who are experiencing homelessness or who are agricultural workers generally DO NOT have income verification. Can we report them as having income at 100 percent and below poverty? No. You can report them as having unknown income, but not as having income below poverty unless you verify this at least annually. However, subject to your health center's financial policies and procedures, you may document their income in your system based on their verbal attestation of their income.
3. If a patient is seen only for dental care, do we report the patient's dental insurance on Lines 712? No. Table 4 reports only patients' medical coverage. All health centers must collect medical coverage information from all patients, even if they have not been provided medical services.
Note: If a patient has Medicaid, Private, or Other Public dental insurance, you may assume they have the same kind of medical insurance. If they DO NOT have dental insurance, you may not assume they are uninsured for medical care.
4. Our state is using Medicaid expansion provisions to assist patients with buying private insurance. Should we count them as Medicaid or Private? If patients are Medicaid expansion patients, report them as Medicaid, Line 8a (this may require looking for specific plan numbers or other identifying characteristics in patients' insurance enrollment). If you are unable to identify Medicaid expansion patients, report them as Private, Line 11.
5. We serve students at a school-based health center. They often DO NOT know what insurance they have, if any, and they have no information on their family's income. Can we report them as having income at 100 percent and below poverty and uninsured? No. You may not report them as having income below poverty and uninsured. Obtain insurance information from the parents of students served at school-based health centers, unless they are exclusively receiving minor consent services. Minor consent services are defined by state law and are generally limited to a very specific range of services, such as those related to contraception, sexually transmitted diseases, and mental health. Not all states provide for them. For all other services, children will require parental consent, and the consent form should include income and insurance information.
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Note: Subject to the health center's policies and procedures, it is acceptable to ask for this information and to assure parents that you will not bill the insurance without their knowledge. If you DO NOT obtain parental consent, report the child as having unknown income. The patient's health insurance is required, even if it is not billed.
6. Do we classify patients in the insurance section as uninsured if their medical insurance did not pay for the visit? No. Always report patients based on their primary medical care insurance, even if the insurance did not pay for the service. Some examples follow:
· Report a patient with Medicare who was seen for a dental visit that was not paid for by Medicare as having Medicare for this table.
· Report a patient with private insurance who had not reached their deductible as a private insurance patient.
7. Should the number of patients by income and insurance source equal the total number of unduplicated patients reported on Tables 3A and 3B and the ZIP Code Table? Yes.
8. Is it possible to have more members in one month (average) than total patients in an insurance category? It is possible, although it would be unusual, for the number of member months for any one payer (e.g., Medicaid) to exceed 12 times the number of patients reported on the corresponding insurance line. As a rule, there is a relationship between the member months reported on Lines 13a and 13b and the insured patients reported on Lines 7 through 11.
9. If we do not receive direct funding under the HCH, MHC, or PHPC programs, do we need to report the total number of special population patients served? Yes. Even health centers that DO NOT receive grant funding for special populations are required to complete the following:
· Line 16 (the total number of patients seen during the calendar year who were agricultural workers or their family members)
· Line 23 (total number of patients known to have experienced homelessness at the time of any service during the calendar year)
· Line 24 (patients of a school-based health center)
· Line 25 (veterans)
· Line 26 (total number of patients served at a health center located in or immediately accessible to a public housing site)
DO NOT complete the details on Lines 1722 if you did not receive HCH funding--only enter the total on Line 23.
DO NOT complete the details on Lines 14 and 15 if you did not receive MHC funding--only enter the total on Line 16.
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10. What timing determines a patient's homeless status and shelter arrangement? For all health centers (regardless of HCH funding status), include the total number of patients who experienced homelessness at any point of service during the year on Line 23. For awardees that receive HCH funding, continue to count patients seen who are no longer experiencing homelessness due to becoming residents of permanent housing for 12 months after their last visit as homeless. For awardees that receive HCH funding, report all patients reported on Line 23 by their shelter arrangement on Lines 1722. Asking health centers to report patients experiencing homelessness by their sheltering arrangements as of their first visit during the calendar year is intended to help health centers determine to which shelter arrangement they should report a patient if shelter status changes during the year.
11. Who do we report as Patients Served at a Health Center Located in or Immediately Accessible to a Public Housing Site on Line 26? Report the total number of patients who were served at any health center service delivery site that you consider (based on your definitions) to be located in or immediately accessible to public housing, regardless of whether or not the health center receives funding under section 330(i), PHPC. This is a site-based count, and the patient's address or residence in public housing is not to be considered.
12. Do the totals need to equal other sections or tables? The following totals must be equal across tables and sections: · ZIP Code Table, Column B must equal Table 4, Line 7, Columns A and B. · ZIP Code Table, Column C must equal Table 4, Lines 8 and 10, Columns A and B. · ZIP Code Table, Column D must equal Table 4, Line 9, Columns A and B. · ZIP Code Table, Column E must equal Table 4, Line 11, Columns A and B. · The sum of Table 3A, Line 39, Columns A and B (total patients by age and gender) must equal Table 3B, Line 8, Column D (total patients by race and Hispanic or Latino/a ethnicity); Table 3B, Line 19 (total patients by sexual orientation); Table 3B, Line 26 (total patients by gender identity); Table 4, Line 6 (total patients by income); and Table 4, Line 12, Columns A and B (total patients by medical insurance status). · The sum of Table 3A, Lines 118, Columns A and B (total patients age 017 years) must equal Table 4, Line 12, Column A (total patients age 017 years). · The sum of Table 3A, Lines 1938, Columns A and B (total patients age 18 and older) must equal Table 4, Line 12, Column B (total patients age 18 and older).
· The sum of Table 3A, Line 39, Columns A and B (total patients by age and gender) must equal Table 4, Line 12, Columns A and B (total patients by insurance status).
The same is true for Grant Reports.
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TABLE 4: SELECTED PATIENT CHARACTERISTICS
Calendar Year: January 1, 2021, through December 31, 2021
Line Income as Percent of Poverty Guideline
Number of Patients (a)
1
100% and below
<blank for demonstration>
2
101150%
<blank for demonstration>
3
151200%
<blank for demonstration>
4
Over 200%
<blank for demonstration>
5
Unknown
<blank for demonstration>
6
TOTAL (Sum of Lines 15) <blank for demonstration>
Line
7 8a 8b 8 9a 9
10a 10b 10 11 12
Principal Third-Party Medical Insurance
None/Uninsured Medicaid (Title XIX) CHIP Medicaid
Total Medicaid (Line 8a + 8b) Dually Eligible (Medicare and Medicaid) Medicare (Inclusive of dually eligible and other Title
XVIII beneficiaries) Other Public Insurance (Non-CHIP) (specify___) Other Public Insurance CHIP
Total Public Insurance (Line 10a + 10b) Private Insurance
TOTAL (Sum of Lines 7 + 8 + 9 +10 +11)
0-17 years old (a)
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
18 and older (b)
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
Line Managed Care Utilization
Medicaid (a)
13a 13b
13c
Capitated Member Months Fee-for-service Member Months
Total Member Months (Sum of Lines 13a + 13b)
<blank for demonstration> <blank for demonstration> <blank for demonstration>
Medicare (b)
<blank for demonstration> <blank for demonstration> <blank for demonstration>
Other Public
Including
Non-Medicaid
CHIP
<blank for demonstration>
(c)
<blank for demonstration>
<blank for demonstration>
Private (d)
<blank for demonstration> <blank for demonstration> <blank for demonstration>
TOTAL (e)
<blank for demonstration> <blank for demonstration> <blank for demonstration>
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TABLE 4: SELECTED PATIENT CHARACTERISTICS (CONTINUED)
Calendar Year: January 1, 2021, through December 31, 2021
Line
14 15 16
17 18 19 20 21a 21 22 23 24
25 26
Special Populations
Migratory (330g awardees only) Seasonal (330g awardees only)
Total Agricultural Workers or Dependents (All health centers report this line)
Homeless Shelter (330h awardees only) Transitional (330h awardees only) Doubling Up (330h awardees only) Street (330h awardees only) Permanent Supportive Housing (330h awardees only) Other (330h awardees only) Unknown (330h awardees only)
Total Homeless (All health centers report this line) Total School-Based Health Center Patients (All health centers report this line)
Total Veterans (All health centers report this line) Total Patients Served at a Health Center Located In or Immediately
Accessible to a Public Housing Site (All health centers report this line)
Number of Patients (a)
<blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration>
Note: Table 4 Cross-Table Considerations:
· The total patients reported by insurance type must match on Table 4 (Lines 712) and the Zip Code Table. For example, total Medicare patients on Table 4 (Line 9) must match the total of the Medicare Column D on the Zip Code Table.
· Charges and collections by payer on Table 9D relates to insurance enrollment on Table 4. For example, dividing Medicaid revenue on Table 9D, Line 3, Column B by Total Medicaid Patients on Table 4, Line 8 equals the average collection per Medicaid patient.
· Reporting of managed care revenue on Table 9D relates to member months on Table 4. Dividing managed care capitation revenue by member months equals average capitation per member per month (PMPM). For example, dividing Medicaid capitated revenue (Table 9D, Line 2a, Column B) by Table 4, Line 13a, Column A equals Medicaid PMPM.
· If you submit Grant Reports, the total number of patients reported on the grant table must be less than or
equal to the corresponding number on the Universal Report for each cell.
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Instructions for Table 5: Staffing and Utilization
Table 5 and the Selected Service Detail Addendum collect data on services provided to patients during the calendar year.
There are no major changes to this table.
TABLE 5: STAFFING AND UTILIZATION
This table provides a profile of health center personnel (Column A), the number of face-to-face clinic visits they render (Column B), the number of virtual visits they render (Column B2), and the number of unduplicated patients served in each service category (Column C).
Service categories include:
· Medical · Dental · Mental health · Substance use disorder · Vision · Other professional · Enabling The patient count will often involve duplication across service categories (e.g., a patient may be reported in both medical and dental patient counts), though it is always unduplicated within service categories (e.g., regardless of number of medical visits or medical providers seen, the patient is only counted once as a medical patient). This is unlike Tables 3A, 3B, and 4, where an unduplicated count of patients across all service categories is reported.
The staffing service categories on Table 5 are consistent with cost categories used for financial reporting and provide adequate detail on personnel categories for program planning and evaluation purposes.
Staffing information is reported only on the Universal Report table, not the Grant Report tables. Grant Reports provide data on patients served in whole or in part with section 330(h) (HCH), section 330(g) (MHC), and/or section 330(i) (PHPC) funding and the visits they had during the year. This includes all visits supported with either grant or non-grant funds.
PERSONNEL FULL-TIME EQUIVALENTS (FTES), COLUMN A
Table 5 includes personnel FTE for all individuals who work in programs and activities that are within Form 5B of the health center's scope of project for all service delivery sites included in the UDS. Report all personnel in terms of annualized FTEs.
· Report FTEs of all personnel supporting health center operations defined by the scope of project in Column A. Personnel may provide services on behalf of the health center under many different arrangements, including but not limited to salaried full-time, salaried part-time, hourly wages, National Health Service Corps (NHSC) assignment, under contract (paid based on hours worked or FTE), interns, residents, preceptors, or donated time.
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· DO NOT report FTEs for individuals who are paid by the health center on a fee-for-service basis in the FTE column, as there is no basis for determining their hours. Visits with providers paid through this arrangement are still reported in Column B or B2 and the patients who received those services are reported in Column C.
Identifying Employment Type and Calculating FTEs
The following describes the basis for determining someone's employment type for purposes of reporting on FTEs:
· One full-time equivalent (FTE = 1.00) describes personnel who worked the equivalent of full-time for one full year. Each health center defines the number of hours for "full-time" work and may define it differently for different positions.
· The FTE is based on employment contracts for providers and other personnel.
· In some health centers, different positions have different definitions of full time. Positions with different time expectations should be calculated on whatever they have as a base for that position. Some positions, per employment contracts, consider working 36 hours per week full time and would be considered 1.00 FTE. In this case, an 18-hour-per-week personnel would be considered 0.50 FTE regardless of whether other personnel in other positions work 40-hour weeks.
· The FTE of personnel receiving full-time benefits for the full year would be considered full-time = 1.00 FTE.
· Hourly personnel with no or reduced benefits who work more than full-time (i.e., overtime) will have an FTE greater than 1.00.
· For personnel who are not paid for full leave (i.e., vacation, holidays, and sick benefits), the effective FTE is calculated by dividing worked hours by adjusted full-time hours (full-time hours minus paid time off hours that full-time personnel receive).
Reporting FTEs in the Appropriate Line on Table 5
Allocate all personnel time by function among the major service categories listed. DO NOT parse out the components of an encounter. The nurse who handles a referral after a visit as a part of that visit would not be allocated out of nursing. The nurse who collects vitals on a patient, who is then placed in the exam room, and later provides instructions on wound care, for example, would not have a portion of the time counted as health education--it is all a part of nursing.
Report an individual who is employed as a full-time provider for a full year as 1.00 FTE regardless of the number of direct patient care hours they provide. Providers who have released time to compensate for on-call hours, have weekly administrative sessions when they DO NOT see patients, or who receive paid leave for continuing education or other reasons are still considered full-time per their employment contract. Similarly, DO NOT count providers who are routinely required to work more than 40 hours per week as more than 1.00 FTE.
The time spent by providers performing tasks in what could be considered non-direct-service clinical activities, such as charting, reviewing labs, filling or renewing prescriptions, returning phone calls, arranging for referrals, participating in quality improvement (QI) activities, supervising, etc., is all considered part of their overall medical care services time and should not be separately reported in a non-clinical support category.
The one exception to this rule is when a chief medical officer/medical director is engaged in non-clinical activities at the corporate level (e.g., attending board of directors or senior management meetings, advocating for the health center before the city council or Congress, writing grant applications, participating in labor negotiations, negotiating fees with insurance companies), in which case time can be allocated to the non-clinical support services category. This does not, however, include non-clinical activities in the medical area, such as supervising the clinical personnel, chairing or attending clinical meetings, or writing clinical protocols.
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Personnel by Major Service Category
Personnel are distributed into categories that reflect the types of services they provide as independent providers. Whenever possible, the contents of major service categories have been defined to be consistent with definitions used by Medicare. The following summarizes the personnel categories; a more detailed, though not exhaustive, list appears in Appendix A.
Medical Care Services (Lines 115)
· Physicians (Lines 17) o Report physicians on Lines 17 consistent with their boarding. Physicians with dual boarding may be allocated into two lines, such as internal medicine and pediatrician, based on time spent or patients seen, but both provider FTE and visits must be allocated. o Report licensed interns and residents on the line designated for the specialty designation they are working toward and credit them with their own visits. (Thus, count a family practice intern as a family physician on Line 1). o DO NOT report psychiatrists, ophthalmologists, pathologists, or radiologists here. They are separately reported on Lines 20a, 22a, 13, and 14, respectively. o DO NOT report naturopaths, acupuncturists, community health aides/practitioners, or chiropractors on these lines. Report these providers on Line 22 (Other Professionals).
· Nurse Practitioners (Line 9a) o Report nurse practitioners (NPs) and advanced practice nurses (APNs) on Line 9a. o DO NOT report psychiatric NPs (included on Line 20b, Other Licensed Mental Health Providers) or certified nurse midwives (CNMs, reported on Line 10) on this line.
· Physician Assistants (Line 9b) o Report physician assistants (PAs) on Line 9b. o DO NOT include psychiatric PAs here (included on Line 20b, Other Licensed Mental Health Providers).
· Certified Nurse Midwives (Line 10) · Nurses (Line 11)
o Report licensed registered nurses, licensed practical and vocational nurses, home health and visiting nurses, clinical nurse specialists, and public health nurses.
· Other Medical Personnel (Line 12) o Report medical assistants, nurses' aides, and all other personnel, including unlicensed interns or residents, providing services in conjunction with services provided by a physician, NP, PA, CNM, or nurse. o DO NOT report non-medical personnel here. DO NOT report personnel dedicated to QI or HIT/EHR informatics here. Report them on Line 29b, Quality Improvement Personnel. DO NOT report patient health records or patient support personnel here. Report them on Line 32, Patient Support Personnel.
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· Laboratory Personnel (Line 13) o Report pathologists, medical technologists, laboratory technicians and assistants, and phlebotomists. o Some or all of nurses' time may be in this category if they are assigned to this responsibility. o DO NOT report the time of a physician (except a pathologist) here.
· X-ray Personnel (Line 14) o Report radiologists, X-ray technologists, and X-ray technicians. o DO NOT include physician time (except radiologists) here, even if they were taking or reading X-rays or performing sonograms.
Dental Services (Lines 1619) · Dentists (Line 16)
o Report general practitioners, oral surgeons, periodontists, and endodontists providing prevention, assessment, or treatment of a dental problem, including restoration.
· Dental Hygienists (Line 17) · Dental Therapists (Line 17a)
o Several states and American Indian or Alaska Native communities license dental therapists. o Report personnel on this line based on state licensing and function. · Other Dental Personnel (Line 18) o Report dental assistants, advanced dental assistants, aides, and technicians. Behavioral Health Services The term "behavioral health" is synonymous with the prevention or treatment of mental health and substance use disorders. All visits, providers, and patients classified by health centers as "behavioral health" must be parsed into mental health or substance use disorders. Centers may choose to identify all behavioral health services as Mental Health Services if there is no way to reasonably split these services. Mental Health Services (Lines 20a20c) Mental health services include psychiatric, psychological, psychosocial, or crisis intervention services. · Psychiatrists (Line 20a) · Licensed Clinical Psychologists (Line 20a1) · Licensed Clinical Social Workers (Line 20a2) · Other Licensed Mental Health Providers (Line 20b) o Report other licensed mental health providers, including psychiatric social workers, psychiatric NPs,
family therapists, and other licensed master's degreeprepared providers.
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· Other Mental Health Personnel (Line 20c) o Report unlicensed personnel and support personnel, including "certified" personnel, who provide counseling, treatment, or support to mental health providers. o Unlicensed interns or residents in any of the professions listed on Lines 20a through 20b are reported on Line 20c, unless they possess a separate license under which they are practicing. Thus, a licensed clinical social worker (LCSW) doing a psychology internship may be reported on Line 20a2 until they receive a license to practice as a psychologist.
Substance Use Disorder Services (Line 21)
o Report personnel who provide substance use disorder services, including substance use disorder social workers, psychiatric nurses, psychiatric social workers, mental health nurses, clinical psychologists, clinical social workers, alcohol and drug abuse counselors, family therapists, and other individuals providing substance use disorder counseling and/or treatment services.
o Neither licenses nor credentials are required by the UDS. Providers are credentialed according to the health center's standards.
o Report medical providers treating patients with substance use diagnoses on Lines 1 through 10, not as substance use disorder providers. Additional information about substance use disorder treatment by medical providers is collected in the Selected Service Details Addendum to this table.
o DO NOT report physicians, NPs, PAs, CNMs, and Certified Registered Nurse Anesthetists (CRNAs) who obtained a Drug Addiction Treatment Act of 2000 (DATA) waiver to provide medication-assisted treatment (MAT) for opioid use disorder here. Report MAT providers on Lines 110 (if medical), Line 20a for psychiatrists, or Line 20b for psychiatric NPs. Additional information about MAT services is collected in Addendum D, Other Data Elements.
Other Professional Health Services (Line 22)
o Report personnel who provide other professional health services. Some common professions include occupational, speech, and physical therapists; registered dieticians; nutritionists; podiatrists; naturopaths; chiropractors; acupuncturists; and community health aides and practitioners. A more complete list is included in Appendix A.
o These professionals are generally credentialed and privileged by the health center's governing board to act in accordance with their approved job descriptions.
o DO NOT report other professionals working in the WIC programs here. Report WIC nutritionists and other professionals working in WIC programs on Line 29a, Other Programs and Services Personnel.
Vision Services (Lines 22a22d)
o Report providers who perform eye exams for detection, care, treatment, and prevention of vision problems, including those that relate to chronic diseases such as diabetes, hypertension, thyroid disease, and arthritis, or for the prescription of corrective lenses.
· Ophthalmologists (Line 22a) o Report MDs specializing in the provision of medical and surgical eye care.
· Optometrists (Line 22b)
· Other Vision Care Personnel (Line 22c) o Report ophthalmologist and optometric assistants, aides, and technicians.
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Pharmacy Services (Line 23)
o Report pharmacists (including clinical pharmacists), pharmacy technicians, pharmacist assistants, and others supporting pharmaceutical services.
o Report licensed clinical pharmacists on Line 23. DO NOT allocate to other clinical or non-clinical lines. o DO NOT report the time (or cost) of personnel spending all or part of their time in assisting patients to
apply for free drugs from pharmaceutical companies through pharmacy assistance programs (PAPs) here. Report them on Line 27a, Eligibility Assistance Workers. If personnel work as a pharmacy assistants (for example) and also provide PAP enrollment assistance, allocate time spent in each category. o DO NOT include time for individuals who work at a 340B contract pharmacy, since they are paid fee-forservice, not based on time. o DO NOT report personnel who manage pharmacy 340B contracts here. Report them on Line 30a as nonclinical support personnel. Enabling Services (Lines 2429)
· Case Managers (Line 24) o Report personnel who assist patients in the management of their health and social needs, including assessment of patient medical and/or social service needs; establishment of service plans; and maintenance of referral, tracking, and follow-up systems. o Include personnel who are trained as--and specifically called--case managers, as well as individuals called care coordinators, referral coordinators, and other local titles. o Case managers may provide health education and/or eligibility assistance in the course of their case management functions. DO NOT parse out this time unless the personnel has dedicated time to other enabling service categories.
· Patient and Community Education Specialists (Line 25) o Report health educators with or without specific degrees.
· Outreach Workers (Line 26) o Report personnel conducting case finding, education, or other services designed to identify potential patients or clients and/or facilitate access or referral of potential health center patients to available health center services.
· Transportation Workers (Line 27) o Report personnel who provide transportation for patients (e.g., van drivers) or arrange for transportation (e.g., for bus or taxi vouchers), including personnel who arrange for local transportation or longerdistance transportation to major cities in extremely remote clinic locations.
· Eligibility Assistance Workers (Line 27a) o Report personnel who provide assistance in securing access to available health, social service, pharmacy, and other assistance programs, including Medicaid, Medicare, WIC, Supplemental Security Income (SSI), food stamps through the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), PAPs, and related assistance programs, as well as personnel hired under the HRSA Outreach and Enrollment grants.
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· Interpretation Personnel (Line 27b) o Report personnel whose full-time or dedicated time is devoted to translation and/or interpretation services. o DO NOT include the portion of the time a nurse, medical assistant, or other support personnel who provides interpretation, translation, or bilingual services during their other activities on this line.
· Community Health Workers (Line 27c) o Report lay members of communities who work in association with the local health care system in both urban and rural environments and usually share ethnicity, language, socioeconomic status, and/or life experiences with the community members they serve. Personnel may be called community health workers, community health advisors, lay health advocates, promotoras, community health representatives, peer health promoters, or peer health educators. o They may perform some or all of the tasks of other enabling services workers. If their time is dedicated to these other functions, report them on those lines. o DO NOT include personnel better classified under other service categories, such as Other Medical Personnel (Line 12) or Other Dental Personnel (Line 18).
· Personnel Performing Other Enabling Service Activities (Line 28) o Report all other personnel performing enabling services not described above. Complete the "specify" field to describe the personnel positions. o If a service does not fit the strict descriptions for Lines 24 through 27c, its inclusion on Line 28 must include a clear detailed statement of what is being reported. o DO NOT use enabling services, especially Other Enabling Services (Line 28), as a catchall, all-inclusive category for services that are not included on other lines. Often, such services belong on Line 29a (Other Programs and Related Services Personnel) or are services that are not separately reported on the UDS. o Check such services with the UDS Support Center or UDS Reviewer prior to submission.
Other Programs and Related Services Personnel (Line 29a)
Some health centers operate programs that (although within their scope of project and often important to the overall health of their patients) are not directly a part of the listed medical, dental, behavioral, or other professional health services (also referred to as "umbrella agencies").
o Report personnel for these programs, such as WIC programs, job training programs, Head Start or Early Head Start programs, shelters, housing programs, child care, frail elderly support programs, adult day health care (ADHC) programs, fitness or exercise programs, public/retail pharmacies, etc., on this line. Complete the "specify" field to describe the personnel positions.
Quality Improvement Personnel (Line 29b)
Although QI is a part of virtually all clinical and administrative positions, some individuals have specific responsibility for the design and oversight of QI systems.
o Report individuals that spend all or a substantial portion of their time dedicated to these activities. They may have clinical, information technology (IT), or research backgrounds, and may include QI nurses, data specialists, statisticians, and designers of HIT (including EHRs and electronic medical records [EMRs]).
o Report personnel who support HIT to the extent that they are working with the QI system on Line 29b.
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o Continue to report personnel who document services in the HIT in the appropriate service category, not here.
o DO NOT include on this line the time of providers, such as physicians or dentists, who are also involved in the QI process. Their time is to remain on the service category lines.
Non-Clinical Support Services (Lines 30a32)
· Management and Support Personnel (Line 30a) o Report the management team, including the CEO, chief financial officer (CFO), chief information officer (CIO), chief medical officer (CMO), chief operations officer (COO), and human resources (HR) director, as well as other non-clinical support and office support personnel. o For medical directors or other personnel whose time is split between clinical and non-clinical activities, report here only that portion of their FTE corresponding to the corporate management function. (See limits on non-clinical time under Personnel Full-Time Equivalents).
· Fiscal and Billing Personnel (Line 30b) o Report personnel performing accounting and billing functions in support of health center operations for services performed within the scope of project. o DO NOT include the CFO here. Report the CFO on Line 30a.
· IT Personnel (Line 30c) o Report information systems technical personnel who maintain and operate the computing systems that support functions performed within the scope of project. o Report IT personnel managing the hardware and software of an HIT (including EHR/EMR) system on Line 30c. o Report IT personnel performing data entry as well as providing help-desk, training, and technical assistance functions as part of the other medical personnel or appropriate service category for which they perform these functions. o DO NOT report IT personnel designing medical forms and conducting analysis of HIT data here. Report as part of the QI functions on Line 29b.
· Facility Personnel (Line 31) o Report personnel with facility support and maintenance responsibilities, including custodians, housekeeping personnel, groundskeepers, security personnel, and other maintenance personnel. If facility functions are contracted (e.g., janitorial services), DO NOT create an FTE; instead report the costs on Line 14 on Table 8A.
· Patient Services Support Personnel (Line 32) o Report intake personnel, front desk personnel, and patient health records personnel.
Note: The non-clinical category for this report is more comprehensive than that used in some other program definitions and includes all such personnel working in a health center, whether an individual's salary was supported by the BPHC grant or other funds included in the scope of project. Where appropriate, and when identifiable, report personnel included in a health center's federally approved budget indirect cost rate here.
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VISITS, COLUMNS B AND B2
Report only clinic and virtual visits that meet the countable visit definitions, as described in the Instructions for Tables that Report Visits, Patients, and Providers section of the UDS Manual.
Report Clinic Visits (Column B) and Virtual Visits (Column B2). These are mutually exclusive and total visits are calculated by adding Columns B and B2.
Clinic Visits, Column B
· Report any documented in-person encounter between a patient and a licensed or credentialed provider who exercises their independent professional judgment in the provision of services to the patient at that time as a visit in Column B.
· Report all such visits that occurred during the calendar year rendered by salaried, contracted, or volunteer providers. Report visits on the same line as the provider who conducted the visit. Most visits reported in Column B will be provided by personnel identified in Column A.
· Visits purchased from contracted providers on a fee-for-service basis should also be reported. Note: DO NOT report encounters that are screenings, tests, or vaccines (such as for COVID-19) as visits. Only report encounters that meet the full definition as a visit.
Virtual Visits, Column B2
· Report any documented virtual (telemedicine) encounter between a patient and a licensed or credentialed provider who exercises their independent professional judgment in the provision of services to the patient at that time as a visit in Column B2.
· Report all such visits that occurred during the calendar year rendered by salaried, contracted, or volunteer personnel. Report visits on the same line as the provider who conducted the visit. Most visits reported in Column B2 will be provided by personnel identified in Column A.
· Virtual visits purchased from contracted providers on a fee-for-service basis should also be reported. Note: Telemedicine is a growing model of care delivery. It is important to remember that payer, state, and federal telehealth definitions, regulations, and billing requirements regarding the acceptable modes of care delivery, types of providers, informed consent, and location of the patient and/or provider are not applicable in determining virtual patient visits for UDS reporting. Virtual Visit Considerations
· Virtual visit reporting should be consistent with the health center's scope of project. · Virtual visits must meet the countable visit definitions. · All reporting requirements regarding multiple visits in the same service category in the same day apply,
except that two different providers based out of two different in-scope service delivery sites may be reported as two visits. · Report virtual visits where: o The health center provider provided care to a patient who was elsewhere (i.e., not physically at the health
center). o The health center patient received services through telemedicine by a non-health-center provider paid for
by the health center or by a volunteer provider who was at the health center.
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o The provider was not physically present at the health center when providing care to the patient, who was in a separate location. The provider must have remote access to the patient's health record to review it and record their activities.
o Interactive, synchronous audio or audio-video telecommunication systems that permit real-time communication between the provider and the patient were used.
o Services are coded and charged as telehealth services, even if a third-party payer does not recognize or pay for such services. Generally, these charges would be similar to a comparable clinic visit charge.
Note: Use codes that will result in accurate identification of virtual visits. These include telehealth-specific codes with the CPT or Healthcare Common Procedure Coding System (HCPCS) codes such as G0071, G0406-G0408, G0425-G0427, G2025, modifier ".95," or Place of Service code "02" to identify virtual visits. · DO NOT report:
o as a virtual visit situations in which the health center does not pay for virtual services provided by a nonhealth-center provider (referral).
o other modes of telemedicine services (e.g., store and forward, remote patient monitoring, mobile health) or provider-to-provider consultations.
o a separate clinic visit at the originating clinic.
Visits Purchased from Non-Personnel Providers on a Fee-For-Service Basis
Report these visits in Column B (clinic) or B2 (virtual) even though no corresponding FTEs are included in Column A. To count, the visit must meet the following criteria:
· the service was provided to a patient of the health center by a provider who is not part of the health center's personnel (neither salaried, volunteer, nor contracted on the basis of time worked) although they meet the center's credentialing policies,
· the service was paid for in full by the health center, and · the service otherwise met the definition of a visit. DO NOT include unpaid referrals, referrals where a third party (e.g., the patient's insurance company) will make the payment directly to the provider, or referrals where only nominal amounts, including facility fees, are paid although the negotiated payment may be less than the provider's "usual, customary, and reasonable" (UCR) rates.
Visit Considerations by Personnel Line
Nurses, Line 11
· Services may be provided under standing orders of a medical provider, under specific instructions from a previous visit, or under the general supervision of a physician, NP, PA, or CNM who has no direct encounter with the patient during the visit. These services must meet the requirement of exercising independent professional judgment.
· Report nurse visits that meet all visit criteria. See Instructions for Visits. Most patient services provided by a nurse DO NOT meet the full visit criteria.
· Report triage services provided by nurses and visiting nurse services when a nurse sees patients independently in the patients' homes to evaluate their condition(s).
· Report visits charged and coded as CPT 99211 only when all components of visit requirements were met.
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· DO NOT report a service if it is a follow up or completion of services from another visit (e.g., nurse calls to check up on how a patient is doing after a visit, nurse checks wound or removes sutures, nurse provides vaccines), even if it occurs at a later date.
· DO NOT report encounters with a nurse where the primary purpose is to conduct a lab test, give an injection, or dispense or administer a drug, regardless of the level of observation needed, as a visit.
· Most states prohibit a licensed vocational nurse or licensed practical nurse from exercising independent professional judgment; DO NOT count visits for them.
Dentists, dental hygienists, and dental therapists, Lines 16, 17, and 17a
· Report only one visit per patient per day, regardless of the number of dental providers who provide services (e.g., dentist and dental hygienist both see the patient) or the volume of service (i.e., number of procedures) provided.
· DO NOT report the application of dental varnishes, fluoride treatments, or dental screenings, absent other comprehensive dental services, as a visit.
· DO NOT report as a dental visit medical providers who examine a patient's dentition or provide fluoride treatments.
· DO NOT report as a dental visit a phone call between the patient and provider for a check up on a completed procedure or service.
· DO NOT credit services of dental students or anyone other than a licensed dental provider with dental visits, even if these individuals are working under the supervision of a licensed dental provider.
· Exception: Report the visits of a supervising dentist's student (i.e., one who is overseeing dental students enrolled in a graduate education program leading to a license as a dentist) as long as the supervising dentist: o has no other responsibilities, including the supervision of other personnel at the time services are furnished by the students, o has primary responsibility for the patients, o reviews the care furnished by the students during or immediately after each visit, and o documents the extent of their participation in the review and direction of the services furnished to each patient.
Other mental health, Line 20c
· Report visits with unlicensed mental health personnel regardless of any billing practices at the center. DO NOT report their visits elsewhere.
Substance use disorder, Line 21
· In programs that include the regular use of narcotic agonists or antagonists or other medications on a regular basis (daily, every three days, weekly, etc.), report only the individualized or group counseling services as visits.
· DO NOT report the counseling by medical or psychiatric providers of patients to determine or diagnose their medical needs, including medication assistance and substance use disorder visits. Report as medical or psychiatry visits based on the provider of these services.
· DO NOT report the dispensing of drugs, regardless of the level of oversight that occurs during that activity.
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Other professional, Line 22 · Report visits by other professional health service providers included in Appendix A. · Describe these services in a clear, detailed statement using the "specify" box. · Check the reporting of other professional services with the UDS Support Center or UDS Reviewer. Vision services, Lines 22a22d · DO NOT report the services of students or anyone other than a licensed vision service provider as vision
services visits. · DO NOT report retinography (imaging of the retina), whether performed by a licensed vision services
provider or anyone else, as a visit unless accompanied by a comprehensive vision exam. · DO NOT report fitting glasses as a visit, regardless of who performs the fitting. Pharmacy, Line 23 · Pharmacy personnel are not considered providers on the UDS (see Appendix A), and therefore visits are not
reported. · Some states license clinical pharmacists whose scope of practice may include ordering labs and reviewing and
altering medications or dosages. Despite this expanded scope of practice, DO NOT report clinical pharmacist encounters with patients as visits. Case managers, Line 24 · Case management visits must be documented in the patient's health record. · When a case manager serves an entire family (e.g., helping with housing or Medicaid eligibility), report only one visit, generally for an adult member of the family, regardless of documentation in other charts. · Case management is rarely the only type of service provided to a patient during the year. · Case managers often contact third parties in the provision of their services. DO NOT count these encounters. Patient and community education, Line 25 · Report only services provided one-on-one with the patient. · Health education is provided to support the delivery of other health care services and is rarely the only type of service provided to a patient during the year. · DO NOT report group education classes or visits.
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DO NOT Report Visits or Patients for Services Provided by the Following:
· Other Medical Personnel, Line 12
· Other Programs and Services, Line 29a
· Laboratory Personnel, Line 13
· Quality Improvement Personnel, Line 29b
· X-ray Personnel, Line 14
· Management and Support Personnel, Line 30a
· Other Dental Personnel, Line 18
· Fiscal and Billing Personnel, Line 30b
· Other Vision Care Personnel, Line 22c
· IT Personnel, Line 30c
· Pharmacy Personnel, Line 23
· Facility Personnel, Line 31
· Outreach Workers, Line 26
· Patient Support Personnel, Line 32
· Transportation Personnel, Line 27
· Eligibility Assistance Workers, Line 27a
· Interpretation Personnel, Line 27b
· Community Health Workers, Line 27c
· Other Enabling Services, Line 28
Additionally, some encounters cannot be reported as countable visits regardless of who provides them. Please review the Services and Individuals Not Reported on the UDS Report section for specifics.
PATIENTS, COLUMN C
A patient is an individual who has at least one countable visit during the calendar year. For further details, see the Instructions for Tables that Report Visits, Patients, and Providers section.
· Report an unduplicated patient count in Column C for each of the seven categories of services shown below for which patients had visits reported in Columns B or B2 during the calendar year.
o Medical services (Line 15)
o Dental services (Line 19)
o Mental health services (Line 20)
o Substance use disorder services (Line 21)
o Vision services (Line 22d)
o Other professional services (Line 22)
o Enabling services (Line 29)
· Report an individual only once as a patient in each service category (e.g., medical, dental) under which they receive services, regardless of the number of visits they had during the year.
· Because patients must have at least one countable visit, the number of patients cannot exceed the number of visits.
· Patients reported on Table 5 must be included as patients on the demographics tables: ZIP Code Table and Tables 3A, 3B, and 4.
· DO NOT report individuals who only receive services for which no visits are generated (e.g., laboratory, imaging, pharmacy, transportation, and outreach).
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SELECTED SERVICE DETAIL ADDENDUM
The Selected Service Detail Addendum to Table 5 provides data on integrated behavioral health. Integrated behavioral health reported in the addendum includes:
· mental health services provided by medical providers during medical visits, · substance use disorder services provided by medical providers during medical visits, and · substance use disorder services provided by mental health providers during mental health visits. The addendum is reported on the Universal Report only.
The information reported in the Selected Service Detail Addendum only reflects providers and their mental health or substance use disorder treatment services not already reported in the mental health and substance use disorder sections on the main part of Table 5. The sum of mental health and substance use disorder services visits reported in the main part of Table 5 and the addendum to Table 5 provide a combined count of mental health and substance use disorder services provided.
The Selected Service Detail Addendum is divided into two service categories: mental health and substance use disorders.
· The Mental Health Services Detail (by type of medical provider), Lines 20a0120a04, is a subset of medical visits and patients reported on Lines 110 in the main section of Table 5.
· The Substance Use Disorder Detail (by type of medical provider), Lines 21a21d, is a subset of medical visits and patients reported on Lines 110 in the main section of Table 5.
· The Substance Use Disorder Detail (by type of mental health provider), Lines 21e21h, is a subset of mental health visits and patients reported on Lines 20a20b in the main section of Table 5.
To identify visits where a mental health or substance use disorder treatment service may have been rendered, include at minimum all visits in which the reported providers coded ICD-10 codes specified on Table 6A, Lines 18 through 19a for substance use disorder treatment and Lines 20a through 20d for mental health treatment.
All visits reported in the addendum will also be included in the main part of Table 5 as either medical or mental health visits. Some visits provided by medical providers may include both mental health and substance use disorder treatment and will be counted in each section of the addendum, in addition to being counted as a medical visit in the main part of Table 5.
Providers, Column A1
· Report the number of individual providers (not FTE) by type who provided mental health and/or substance use disorder services. Medical providers can be counted once in each section if they provide both mental health and substance use disorder services.
· If the provider is a contract provider paid by visit or service, DO NOT count an FTE on the main part of Table 5, but count the provider in the addendum.
Clinic Visits, Column B
· Report the number of clinic (in-person) visits, by provider type, where the service in whole or in part included treatment for mental health (on Lines 20a01 through 20a04) or substance use disorder services (on Lines 21a through 21h).
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Virtual Visits, Column B2
· Report the number of virtual visits, by provider type, where the service in whole or in part included treatment for mental health (on Lines 20a01 through 20a04) or substance use disorder services (on Lines 21a through 21h).
Patients, Column C
· Report the number of patients seen for a clinic or virtual mental health or substance use disorder service by provider(s) in the given line.
· Report patients (and their visits) for each type of provider listed who were seen during the year for these services. This may result in the same patient appearing on more than one line in the addendum.
FAQS FOR TABLE 5 AND SELECTED SERVICE DETAIL ADDENDUM
1. How do we determine FTE? Use employment contracts to determine FTE. For example, a physician hired as a full-time personnel who, per their employment contract, is only required to work four 9-hour sessions (36 hours) per week, is considered full-time.
2. Our physicians work 35-hour weeks. Do we report as 0.875 (35 divided by 40) FTE? No. Count them as 1.00 FTE. BPHC does not require 40-hour workweeks. Use whatever workweek time is considered full-time.
3. Do we calculate FTE for personnel with no or reduced benefits the same way we do for personnel receiving full benefits? No. If personnel receive no or reduced benefits, calculate FTE based on paid hours. For example, in a health center that has a 40-hour workweek (2,080 hours/year), an individual who works 20 hours per week (i.e., 50 percent time) is reported as 0.50 FTE; an individual who works full-time for 4 months out of the year is reported as 0.33 FTE (4 months ÷ 12 months). If an individual with no benefits works 2,200 hours out of 2,080 full-time hours, report as 1.06 FTE.
4. How do I report the FTEs for a provider who regularly sees patients 75 percent of the time and covers after-hours call for the remaining 25 percent of their salary? Report personnel who are hired as full-time providers as 1.00 FTE regardless of the number of direct patient care hours they provide. Count as 1.00 FTE providers hired as full-time who have released time to compensate for on-call hours, who have released time to compensate for hours spent on clinical committees, or who receive leave for continuing education or other activities.
DO NOT adjust for the time spent by a physician (for example) while not in contact with the patient, such as charting, reviewing labs, filling prescriptions, returning phone calls, or arranging for referrals. These tasks are considered part of their time as a physician. The exception to this rule is when a medical director or chief medical officer is engaged in non-clinical activities at the corporate level, in which case time is allocated to the non-clinical category. This does not, however, include non-clinical activities in the medical area, such as chairing or attending meetings, supervising personnel, writing clinical protocols, designing formularies, setting hours, or approving specialty referrals.
Note: Count loan-repayment recipients as full-time. Note that the FQHC Medicare intermediary has different definitions for full-time providers; these are not to be used for UDS reporting.
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5. Our nurses perform services that cross service categories. Do we allocate the FTE and visit activity accordingly? That depends on if their time is distinctly allocated by function among the major service categories. If, for example, a full-time nurse provides direct medical services and provides some patient education while seeing the patient for medical care, they would be counted as 1.0 FTE on Line 11 (Nurses). If that nurse provided case management services during 10 dedicated hours per week and provided medical care services for the other 30 hours per week, the time would be allocated as 0.25 FTE case manager (Line 24) and 0.75 FTE nurse (Line 11).
6. If I report costs for case management services on Table 8A, do I have to report case managers on Table 5? If a health center reports costs for case management services, one would expect to see case managers reported on Table 5, unless the service was contracted with no personnel time specifically identified. Similarly, if there are personnel on Table 5, one would expect costs on Table 8A unless personnel are volunteers. Some services DO NOT involve personnel. Spending funds on bus tokens, for example, would involve transportation costs on Table 8A, but no personnel on Table 5.
7. How are contracted personnel and their activities reported on Table 5? If the contracted personnel is paid based on time worked (for example, one day per week), report the FTE on Table 5, Column A, and report the visits and patients receiving services from this provider. (See Appendix B for a more complete discussion of calculating the FTE of these providers.) If the contracted personnel is paid on a fee-for-service basis, DO NOT report FTE on Table 5, Column A, but report the visits and patients. This may require additional explanation in your UDS Report, but it is not an error.
8. How are behavioral health functions reported on Table 5? In some systems, behavioral health is another name for mental health, and the personnel and visits are reported on Lines 20a through 20c. However, some health centers have merged the positions of mental health provider and substance use disorder provider into a single position, which they call a behavioral health provider. In this instance, the health center has two choices. The first is to assert that substance use disorder problems are mental health problems and classify its behavioral health personnel as mental health personnel on Lines 20a, 20a1, 20a2, 20b, or 20c. Another method is to carefully record the time and activities of these dual function providers. In this case, identify each visit as either a mental health visit or a substance use disorder visit so the patients and visits can be correctly classified. In addition, keep track of providers' time so that FTEs on Table 5 (and associated costs on Table 8A) can be accurately allocated and recorded to the appropriate line.
9. If a psychiatric NP provides mental health and substance use disorder services to the same patient during a visit, how should we count this? Because substance use disorder is also seen as a mental health diagnosis, count the visit under mental health for the main part of Table 5. DO NOT count the visits as one of each type. In the addendum, separately report the substance use disorder service provided by the personnel during the visits. Classify the provider and costs (on Table 8A) as mental health.
10. Do I count the time of volunteer providers, interns, or residents? Yes. Volunteers, interns, and residents are licensed practitioners and their time is counted like that of any other practitioner. Note, however, that some may work shorter days because they are in educational sessions, may have more vacation time or other time off than other practitioners, or, in the case of volunteers, DO NOT have vacations or holidays. This would make them less than full-time. See the more complete discussion of counting volunteers, interns, and residents in Appendix B.
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11. We contract with many licensed physicians to read our test results: an ophthalmologist reads the retinal photos that our medical assistant takes, a radiologist over-reads the X-rays that our X-ray tech takes, the outside laboratory's pathologist provides the test results from their machines, and a consulting cardiologist confirms findings of our electrocardiograms (EKGs). Should we report them as personnel, and do we report what they do as visits? Report the costs for tests on Table 8A.
DO NOT report these activities, which are important to the provision of comprehensive care to patients, separately.
Tests are not counted as visits anywhere in the UDS.
DO NOT report the time (FTE) of any individual who is working on a contract basis when the payment is not for their time worked but, rather, for the activity that they perform.
Under some circumstances, the EHBs may identify a system edit (costs with no personnel) that you will need to explain.
12. Where do we report community health workers that we employ? Report personnel with responsibility as community health workers on Line 27c. If, however, you are using this term to describe someone who is performing the tasks normally associated with a medical assistant, an outreach worker, or another job title, count them in the corresponding category.
13. Where do we report medical providers whose only activity at a visit is providing MAT? Report this activity on the line of the credentialed personnel providing this treatment (i.e., physicians are counted in medical [Lines 18], even if they only provide substance use disorder services at the visit). Additionally, report the activity in the substance use disorder section of the addendum (i.e., physicians are counted on Line 21a of the addendum).
DO NOT count them on the substance use disorder line of the main part of Table 5.
14. How do I count participants in a group session? Only group treatment sessions for substance use disorders, mental health, or behavioral health may be counted. The visit must be recorded in each participant's chart.
Each patient charted in a group session must be billed and the service must be paid consistent with health center policy by either the patient, insurance, or another contract maintained by the health center. If some patients or visits are billed and others are not, count only those that are billed.
DO NOT count a group encounter with a patient that is not recorded in a patient health record.
DO NOT report group medical visits or group health education visits. Although in some instances they may be billable, the UDS specifically does not count these as visits.
15. Are virtual/telemedicine visits only permitted after a clinic visit at the health center? No, although virtual visits may occur from a referral from a clinic visit. If the first or only visit is a countable virtual visit, the health center must register the patient and collect and report all relevant demographic, service, clinical, and financial data on the UDS tables.
65 2021 UDS MANUAL | Instructions for Table 5
UDS SUPPORT CENTER, 866-UDS-HELP, UDSHELP330@BPHCDATA.NET 16. Should the total number of patients reported on Table 3A be equal to the sum of the several types of
service patients on the main part of Table 5? Not unless the only services you provide are medical services. On Table 5, report patients for each type of service received. For example, count a patient who receives both medical and dental services once as a medical patient on Line 15 and once as a dental patient on Line 19. 17. Which provider types and what activity are included in the addendum? Medical providers who provide mental health or substance use treatment are included in the addendum. Mental health providers who provide substance use treatment are also included in the addendum. Examples of provider activity reported in the addendum include: · A physician who sees a patient for treatment of depression. · An NP seeing a patient for diabetes who is also showing signs of anxiety. · A PA providing MAT services to a patient with opioid use disorder. · A licensed clinical psychologist seeing a patient for mental health problems exacerbated by a substance
use disorder.
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TABLE 5: STAFFING AND UTILIZATION
Calendar Year: January 1, 2021, through December 31, 2021
Line
1 2 3 4 5 7 8 9a 9b 10 10a 11 12 13 14 15
16 17 17a 18 19 20a 20a1 20a2 20b 20c 20 21 22
Personnel by Major Service Category
Family Physicians General Practitioners Internists Obstetrician/Gynecologists Pediatricians Other Specialty Physicians
Total Physicians (Lines 17) Nurse Practitioners Physician Assistants Certified Nurse Midwives
Total NPs, PAs, and CNMs (Lines 9a10) Nurses Other Medical Personnel Laboratory Personnel X-ray Personnel
Total Medical Care Services (Lines 8 + 10a through 14)
Dentists Dental Hygienists Dental Therapists Other Dental Personnel
Total Dental Services (Lines 1618) Psychiatrists Licensed Clinical Psychologists Licensed Clinical Social Workers Other Licensed Mental Health Providers Other Mental Health Personnel
Total Mental Health Services (Lines 20ac) Substance Use Disorder Services
Other Professional Services (specify___)
FTEs (a)
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
Clinic Visits (b)
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <cell not reported> <cell not reported> <blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
Virtual Visits (b2)
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <cell not reported> <cell not reported> <blank for demonstration>
Patients (c)
<cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
<cell not reported> <cell not reported> <cell not reported> <cell not reported> <blank for demonstration> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <blank for demonstration> <blank for demonstration> <blank for demonstration>
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TABLE 5: STAFFING AND UTILIZATION (CONTINUED)
Calendar Year: January 1, 2021, through December 31, 2021
Line Personnel by Major Service Category
FTEs (a)
22a 22b 22c 22d 23 24
25
26 27 27a 27b 27c 28 29 29a 29b 30a 30b 30c 31 32 33
34
Ophthalmologists
Optometrists
Other Vision Care Personnel
Total Vision Services (Lines 22ac)
Case Managers
Pharmacy Personnel
Patient and Community Education Specialists
Outreach Workers Transportation Personnel Eligibility Assistance Workers Interpretation Personnel Community Health Workers Other Enabling Services (specify___)
Total Enabling Services (Lines 2428) Other Programs and Services (specify___)
Quality Improvement Personnel Management and Support Personnel Fiscal and Billing Personnel IT Personnel Facility Personnel Patient Support Personnel
Total Facility and Non-Clinical Support Personnel (Lines 30a32) Grand Total (Lines
15+19+20+21+22+22d+23+29+29a+29b+33)
<blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration>
Clinic Visits (b)
<blank for demonstration>
<blank for demonstration>
<cell not reported>
<blank for demonstration>
<cell not reported> <blank for demonstration> <blank for demonstration> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported>
<blank for demonstration>
<cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported>
Virtual Visits (b2)
<blank for demonstration> <blank for demonstration> <cell not reported>
<blank for demonstration>
<cell not reported>
<blank for demonstration> <blank for demonstration> <cell not reported>
<cell not reported>
<cell not reported>
<cell not reported>
<cell not reported>
<cell not reported>
<blank for demonstration>
<cell not reported>
<cell not reported>
<cell not reported>
<cell not reported>
<cell not reported>
<cell not reported>
<cell not reported>
<cell not reported>
Patients (c)
<cell not reported> <cell not reported> <cell not reported> <blank for demonstration>
<cell not reported> <cell not reported>
<cell not reported>
<cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported>
<blank for demonstration>
<cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported> <cell not reported>
<blank for demonstration>
<blank for demonstration>
<cell not reported>
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TABLE 5: SELECTED SERVICE DETAIL ADDENDUM
Calendar Year: January 1, 2021, through December 31, 2021
Line
Personnel by Major Service Category: Mental Health Service Detail
20a01 Physicians (other than Psychiatrists)
20a02 Nurse Practitioners
20a03 Physician Assistants
20a04 Certified Nurse Midwives
Line
Personnel by Major Service Category: Substance Use Disorder Detail
21a Physicians (other than Psychiatrists)
21b Nurse Practitioners (Medical)
21c Physician Assistants
21d Certified Nurse Midwives
21e Psychiatrists
21f Licensed Clinical Psychologists
21g Licensed Clinical Social Workers
21h Other Licensed Mental Health Providers
Personnel
(a1)
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
Personnel
(a1)
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
Clinic Visits (b)
<blank for demonstration>
<blank for demonstration>
<blank for demonstration>
<blank for demonstration>
Clinic Visits (b)
<blank for demonstration>
<blank for demonstration>
<blank for demonstration>
<blank for demonstration>
<blank for demonstration>
<blank for demonstration>
<blank for demonstration>
<blank for demonstration>
Virtual
Visits (b2)
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
Virtual
Visits (b2)
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
Patients (c)
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
Patients (c)
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
Note: Table 5 and Addendum Cross-Table Considerations:
· Total patients on Table 5, Column C, should be greater than the total number of patients on Table 3A (unless only one type of service is offered at the health center).
· Patients with medical visits on Table 5 are generally eligible for inclusion in eCQMs reported on Tables 6B and 7.
· The personnel on Table 5 is routinely compared to the costs on Table 8A. See the crosswalk of comparable fields in Appendix B.
· Billable visits reported on Table 5 should relate to patient charges reported on Table 9D.
· If you submit Grant Reports, the total number of patients and visits reported on the grant table must be less than or equal to the corresponding number on the Universal Report for each cell.
· Table 6A activity reported for substance use disorder and mental health treatment are compared to the Table 5 addendum and the main part of Table 5 mental health and substance use lines.
· The activity reported on the Table 5 addendum must also be included in the main part of Table 4, medical plus mental health lines.
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Instructions for Table 6A: Selected Diagnoses and Services Rendered
This table collects data on selected diagnoses and selected services rendered. The data source for this table is your billing system, lab reports, and/or other information captured in your HIT systems or EHRs.
Table 6A does not reflect the full range of diagnoses and services rendered by a health center. The selected diagnoses and services represent those that are prevalent among Health Center Program patients, have been regarded as sentinel indicators of access to primary care, or are of special interest to HRSA.
Some diagnosis and service codes have been updated. Changes are included in the table and outlined in the Table 6A Code Changes file found at the UDS training website. In addition, a new line has been added to report COVID-19 vaccines provided to health center patients (previously reported in Appendix E).
SELECTED DIAGNOSES, LINES 120F
Lines 1 through 20f present the name and applicable ICD-10-CM codes for the diagnosis or diagnostic range/group. Wherever possible, diagnoses have been grouped into code ranges.
· Report all visits (both in-person clinic and virtual) and patients where the provider-assigned diagnostic code is included in the range/group of ICD-10-CM codes shown in the given line.
· Report diagnoses that were made as part of documented, countable visits with licensed or credentialed medical, dental, mental health, substance use disorder, or vision providers only.
· Report all diagnoses rendered at a specific visit. However, DO NOT count "active diagnoses" present at the time of a visit but not addressed during the visit.
· Use age at time of visit for diagnoses with specified age ranges. · DO NOT report a diagnosis visit by an other professional or enabling service provider. · DO NOT report a diagnosis when it is listed, but not diagnosed or treated.
Selected Diagnoses Visits and Patients, Columns A and B
Column A, Number of Visits by Diagnosis Regardless of Primacy
· Report the total number of visits (in-person clinic and/or virtual) during the calendar year where the indicated diagnosis, regardless of primacy, is listed in the HIT/EHR or visit/billing record.
· Report on Lines 120f each included diagnosis made at a visit, regardless of the number of diagnoses listed for the visit. For example, count a patient visit with a diagnosis of hypertension and a diagnosis of diabetes once on Line 9 and once on Line 11.
Column B, Number of Patients with Diagnosis
· Report each patient who had one or more visits (in-person clinic and/or virtual) during the year that were reported in the corresponding cell in Column A.
· Report a patient only once on any given line, regardless of the number of visits made for that specific diagnosis or family of diagnoses.
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SELECTED TESTS/SCREENINGS, LINES 2126D
Lines 21 through 26d present the name and applicable ICD-10-CM diagnostic, HCPCS, and/or CPT procedure codes for selected tests, screenings, and preventive services. On several lines, CPT codes, HCPCS, and ICD-10CM codes are provided. Use either the CPT codes or HCPCS or the ICD-10-CM codes for any specific visit, not all code types.
· Report all visits meeting the selection criteria that are provided to a health center patient, part of a countable visit, or as follow-up to a countable visit.
· Only report tests or procedures (e.g., mammograms, X-rays, tomography) that are: o performed by the health center, or o not performed by the health center, but paid for by the health center, or o not performed by the health center or paid for by the health center, but whose results are returned to the health center provider to evaluate and provide results to the patient.
· During a visit with the provider, selected screenings or tests may be ordered. Report only completed services in this section even if they were done at a later date.
· Use age at time of visit for diagnoses and tests with specified age ranges. Note: ICD-10-CM codes for some services (such as mammography and Pap tests) are listed to ensure capture of procedures that are done by the health center but may be coded with a different CPT code for state reimbursement under Title X or BCCCP. In some instances, payers (especially governmental payers) and labs ask health centers to use different codes for services. In these instances, health centers should internally map these codes to the specified list for reporting purposes.
Selected Tests/Screenings Visits and Patients, Columns A and B
Column A, Number of Visits
· Report the total number of visits (in-person clinic and/or virtual) for which one or more of the listed diagnostic tests, screenings, and/or preventive services were provided at the time of a visit or subsequent to a visit.
· Codes for these services may either be diagnostic (ICD-10-CM) codes or procedure (CPT or HCPCS) codes. · During a single visit, more than one test, screening, or preventive service may be provided. Report each on
the applicable line. If they are on the same line, report only one visit. Column B, Number of Patients
· Report patients who had a visit (in-person clinic and/or virtual) during the calendar year for which one or more of the selected diagnostic tests, screenings, and/or preventive services listed on Lines 2126d were provided.
· Report patients who received more than one type of service during a single visit on each applicable line. For example, if a patient had a Pap test and contraceptive management during the same visit, this patient would be counted on both Lines 23 and 25.
· Report a patient only once per service, regardless of the number of times a patient receives a given service. For example, an infant who has an immunization at each of several well-child visits in the year has each visit reported in Column A but is counted only once in Column B.
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Note: Include follow-up services related to a countable visit. Thus, if a provider asks that a patient return in 30 days for a flu shot, when that patient presents, the shot is counted because it is legally considered to be a part of the initial visit. DO NOT report an encounter with an individual who is not a health center patient who comes in just for a flu shot during a health centerrun flu clinic and without a specific referral from a prior visit.
DENTAL SERVICES, LINES 2734
Lines 27 through 34 present the name and applicable American Dental Association (ADA) procedure codes for selected dental services. These services may be performed only by a dental provider who is reported on Lines 16 17a on Table 5 or by an in-scope dental contractor paid by the health center. Wherever appropriate, services have been grouped into code ranges. For these lines, the concept of a "primary" code is neither relevant nor used. All services are reported.
Dental Services Visits and Patients, Columns A and B
Column A, Number of Visits
· Report the total number of visits at which one or more of the listed diagnostic tests, screenings, and/or dental services were provided.
· During one visit, more than one test, screening, or dental service may be provided. Report each procedure, screening, or test on each separate, applicable line. If they are on the same line, report only one visit. For example, if a patient had more than one tooth filled during a visit, report only one visit for restorative services (Line 32), not one visit per tooth.
Column B, Number of Patients
· Report patients who had at least one visit with a dental professional during the calendar year for each of the selected dental services listed.
· Only report services that are provided at or as follow-up to countable visits (e.g., a comprehensive oral exam). · Report a patient who had two teeth repaired and sealants applied during a single visit once on Line 30 and
once on Line 32. · DO NOT report services provided by personnel other than a licensed dentist, dental hygienist, dental
therapist, or personnel working under their direct supervision. · DO NOT report fluoride treatments or varnishes that are applied outside of a comprehensive treatment plan,
including when provided as part of a community service at schools, on this table or as a visit on Table 5.
SERVICES PROVIDED BY MULTIPLE ENTITIES
Take care when multiple entities are involved with a service. Use the following rules and general examples to guide reporting:
· Report the service if a health center provider orders and performs the service. For example, count a rapid HbA1c test ordered by a health center provider and performed in the health center lab.
· If the health center provider orders a test (e.g., HIV test) and the sample is collected at the health center and then sent to a reference lab for processing, report the test regardless of whether the test is paid for by the patient, the patient's insurance company,9 a government entity, or the health center.
9 Billing rules require that the charge for a lab test ordered by a provider be sent directly to a third party (including Medicaid and Medicare) and not to the provider or the health center.
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· Report a test when the health center provider asks a patient to get that test from a third party and the health center provider receives and reviews the test results with the patient. For example, report mammograms performed by a third-party provider that a health center contracts with and for which the health center reviews the result with the patient.
· DO NOT report vaccinations performed by a health department when patients are referred to a city or county health department and the health center does not pay for the service, including referrals where a third party (e.g., the patient's insurance company) will make the payment.
· DO NOT report a test or service that a provider asks the patient to get from a third-party provider (e.g., an HIV test referred to a Ryan White program) that does not bill the health center, including referrals where a third party (e.g., the patient's insurance company) will make the payment if the test or service results are reviewed and acted on by the third-party provider. For example, DO NOT count mammograms performed by the county health department for which the county will follow up with the patient directly and the health center did not pay for the service. (These are generally noted in Column III: Formal Written Referral Arrangement [Health center DOES NOT pay] of Form 5A: Services Provided).
FAQS FOR TABLE 6A
1. If a case manager or health educator serves a patient who, for example, has diabetes, we often report that diagnostic code for the visit. Should we report this on Table 6A? No. Report on Table 6A only visits with medical, dental, mental health, substance use disorder, and vision providers who are diagnosing according to their own field.
2. The instructions for this table call for diagnoses and services at visits. If we provide the service but it is not counted as a visit (such as an immunization given at a health fair), should it be reported on this table? Report the visit if a service is provided because of a prescription or plan from an earlier counted visit, such as if a provider asks a patient to come back in four months for a mammogram.
DO NOT report services given at health fairs to an individual who is not a health center patient, regardless of who provides the service or the level of documentation that is done, such as an HIV test at a health fair.
DO NOT report services that are self-referrals where no clinical visit is necessary or provided, such as an individual coming in for a flu shot.
3. Some diagnostic and/or procedure codes in our system are different from the codes listed. What do we do? It is possible that information for Table 6A is not available using the codes shown because of idiosyncrasies in state or clinic billing systems. Generally, these involve situations where (a) the state uses unique billing codes other than the normal CPT code for state billing purposes (e.g., EPSDT) or (b) internal or state confidentiality rules mask certain diagnostic data. The following table provides examples of problems and solutions:
Line Problem
Potential Solution
1
HIV diagnoses are kept confidential, and Include the alternative codes used at your center on these lines
alternative diagnostic codes are used.
as well.
23
Pap tests are charged to a state BCCCP Add these special codes to the other codes listed.
using a special code.
26
Well-child visits are charged to the state Add these special codes to the other codes listed and count all
EPSDT program using a special code
such visits. DO NOT count EPSDT follow-up visits in this
(often starting with W, X, Y, or Z).
category.
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4. The instructions specifically say that the source of information for Table 6A is "billing systems or HITs." There are some services for which we DO NOT bill and/or for which there are no visits in our system. What do we do? Although health centers are only required to report data derived from billing systems or HITs, the reported data may understate services in the circumstances described below. In today's EHRs, diagnoses and/or services should be captured in one of the templates available. To more accurately reflect the level of service, use other codes in the system to enable the tracking.
DO NOT report referrals for which you DO NOT pay or evaluate results and provide back to the patient (e.g., sending patients to the county health department for mammograms).
Line 21 Multiple
22
23 24 25
Problem
HIV test samples are collected by us but processed and paid for by the state and DO NOT show on the visit form or in the billing system. Tests (HIV tests, Pap tests, etc.) are ordered and samples collected by us. We send samples to a reference lab for processing, but the lab bills Medicaid or Medicare directly. Mammograms are paid for by us but are conducted by a contractor and DO NOT show in the billing system for individual patients.
Pap tests are processed and paid for by the state and DO NOT show on the visit form or in the billing system. Flu shots and other vaccinations are not counted because the vaccines are obtained at no cost to the health center.
Contraceptive management is funded under Title X or a state family planning program and does not have a Z30diagnosis or ICD V25- attached to it.
Potential Solution · Preferred: Use the correct code, but report a zero charge. · Alternative: Use documented completed lab results returned
to the health center.
· Preferred: Use the correct code, but report a zero charge. · Alternative: Use documented completed lab results returned
to the health center.
· Preferred: Use the correct code, but report a zero charge. · Alternative: Use the bills from the independent contractor to
identify the mammograms conducted and the patients who received them and report these numbers. · Preferred: Use the correct code, but report a zero charge.
· Preferred: Use the correct code, but report a zero charge. · Alternative: Use documented completed lab results returned
to the health center. · Preferred: Add a "dummy code" you can map to the Z30- or
V25- code. · Alternative: Code with both the Z30- (or V25-) and the
state-mandated code, but suppress printing of the Z30- or V25- code. Take care not to count the same visit twice.
5. Are we required to report all diagnoses and services rendered during a visit? Yes and no. No, because there are many diagnoses that may be used but not reported on Table 6A. Yes, because documentation and reporting of all diagnoses (not just primary diagnosis) and services rendered during all UDS-countable visits are required. It is important that you appropriately document the breadth of comprehensive services delivered during each visit, including behavioral health services provided during a medical visit (e.g., SBIRT and/or treatment and counseling for mental health and substance use disorders).
6. What happens if the CPT, HCPCS, or ICD-10-CM codes change again? The codes are reviewed annually by the UDS Support Center personnel. If you think a CPT, ICD, HCPCS, or ADA code for a measure is not reflected in the list or has changed, contact the UDS Support Center at udshelp330@bphcdata.net. Personnel will review the code(s) with BPHC and incorporate approved changes to codes in the manual for future reporting.
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7. Are there ICD-10-CM codes for PrEP management? No. Health centers could use the following codes to help identify patient visits that may include counseling on or initiation of PrEP or that may be associated with currently prescribed PrEP, based on risk for HIV exposure. Possible ICD-10 codes: Z11.3, Z11.4, Z20.2, Z20.6, Z51.81, Z71.51, Z71.7, Z79.899 Possible CPT codes: 99401 through 99404 Possible RxNORM Codes: 1721603, 1747692, 276237, 322248, 495430 Please note, this is not an exhaustive list. Limit to emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) or emtricitabine/tenofovir alafenamide (FTC/TAF) for PrEP. DO NOT report these ICD, CPT, or RxNORM codes on Table 6A. They only serve as a recommendation to help health centers identify reportable PrEP management.
8. Should suspected, possible, probable, or inconclusive SARS-CoV-2 (novel coronavirus) disease screening and/or tests be reported as diagnosed? No. If the provider documents "suspected," "possible," "probable," or "inconclusive" coronavirus (SARSCoV-2) disease, DO NOT assign code U07.1 and DO NOT report the patient as having this diagnosis. Only report confirmed novel coronavirus cases.
9. If a patient presents to the health center with pneumonia or other health conditions caused by coronavirus (SARS-CoV-2) disease, is the other health condition reported on Table 6A? Assign code U07.1 and the appropriate ICD-10 code associated with the other health condition. Documentation in the patient's health record and reporting of all diagnoses (not just primary diagnosis) and services rendered during the visit are required, if applicable. For example, if a patient has pneumonia confirmed due to coronavirus (SARS-CoV-2) disease, assign and report codes U07.1 (coronavirus disease) on Line 4c and J12.89 (other viral pneumonia) on Line 6a.
10. We DO NOT perform some services and tests and refer these out. Can we count these? Possibly. If you perform the service, or if you DO NOT perform the service or test but paid another provider to provide the requested service, or if the results are returned to the health center provider to evaluate and provide results back to the patient, you may report these services. The following examples illustrate these rules:
· Report a Pap test specimen collected by the health center but read by an outside pathologist who then bills a third party.
· Report a blood draw performed by the health center and sent to an outside lab who then bills Medicaid and sends the results back to the health center.
· DO NOT report the referral of a patient to the local hospital or county health department for a mammogram where the local hospital or county health department providers perform the test and provide results directly to the patient.
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UDS SUPPORT CENTER, 866-UDS-HELP, UDSHELP330@BPHCDATA.NET 11. Can we count patients on multiple lines if they had more than one type of service at a visit?
If patients receive multiple services at one visit and the services are reflected on this table, you may report the patient and visit on each applicable line. The following examples illustrate these rules: · Report a patient with hypertension who also receives an HIV test on Line 11 (hypertension) and on Line
21 (HIV test). · If both an HIV test and a Pap test were provided during a visit, then report a visit on both Line 21 (HIV
test) and Line 23 (Pap test). · If a patient receives multiple immunizations at one visit, report only one visit on Line 24. · Report a patient who comes in for an annual physical and a flu shot. Report this patient on Line 24a (flu
shot) but not on any diagnostic line (since annual physical is not collected on this table).
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TABLE 6A: SELECTED DIAGNOSES AND SERVICES RENDERED
Calendar Year: January 1, 2021, through December 31, 2021
SELECTED DIAGNOSES
Line
Diagnostic Category
Selected Infectious and Parasitic Disease
12 3
Selected Infectious and Parasitic Diseases Symptomatic/Asymptomatic human immunodeficiency virus (HIV) Tuberculosis
4
Sexually transmitted infections
4a Hepatitis B
4b 4c
Selected Diseases of the Respiratory System
5 6
Hepatitis C Novel coronavirus (SARS-CoV2) disease Selected Diseases of the Respiratory System Asthma
Chronic lower respiratory diseases
6a
Selected Other Medical Conditions
7
Acute respiratory illness due to novel coronavirus (SARS-CoV-2) disease
Selected Other Medical Conditions Abnormal breast findings, female
8
Abnormal cervical findings
9
Diabetes mellitus
10 Heart disease (selected)
11 Hypertension 12 Contact dermatitis and other
eczema 13 Dehydration 14 Exposure to heat or cold
14a Overweight and obesity
Applicable ICD-10-CM Code
Selected Infectious and Parasitic Diseases
B20, B97.35, O98.7-, Z21
A15- through A19-, O98.0-
A50- through A64B16.0 through B16.2, B16.9, B17.0, B18.0, B18.1, B19.1-, O98.4B17.1-, B18.2, B19.2U07.1
Selected Diseases of the Respiratory System
J45J40 (count only when code U07.1 is not present), J41- through J44-, J47J12.89, J20.8, J40 (count only when code U07.1 is present), J22, J98.8, J80 Selected Other Medical Conditions
C50.01-, C50.11-, C50.21-, C50.31-, C50.41-, C50.51-, C50.61-, C50.81-, C50.91-, C79.81, D05-, D48.6-, D49.3, N60-, N63-, R92C53-, C79.82, D06-, R87.61-, R87.629, R87.810, R87.820 E08- through E13-, O24- (exclude O24.41-) I01-, I02- (exclude I02.9), I20through I25-, I27-, I28-, I30through I52I10- through I16-, O10-, O11-
L23- through L25-, L30- (exclude L30.1, L30.3, L30.4, L30.5), L58E86-
T33-, T34-, T67-, T68-, T69-, W92-, W93-, X30-, X31-, X32E66-, Z68- (exclude Z68.1, Z68.20 through Z68.24, Z68.51, Z68.52)
Number of Visits by Diagnosis Regardless of Primacy (a)
Selected Infectious and Parasitic Diseases <blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration> Selected Diseases of the Respiratory System <blank for demonstration> <blank for demonstration>
<blank for demonstration>
Selected Other Medical Conditions <blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
Number of Patients with Diagnosis (b)
Selected Infectious and Parasitic Diseases <blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration> Selected Diseases of the Respiratory System <blank for demonstration> <blank for demonstration>
<blank for demonstration>
Selected Other Medical Conditions <blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
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Line
Diagnostic Category
Applicable ICD-10-CM Code
Selected Childhood Conditions (limited to ages 0 thru 17)
Selected Childhood Conditions
Selected Childhood Conditions (limited to ages 0 thru 17)
(limited to ages 0 through 17)
15 Otitis media and Eustachian tube H65- through H69-
disorders
16 Selected perinatal/neonatal
A33, P19-, P22- through P29-
medical conditions
(exclude P29.3-), P35- through
P96- (exclude P54-, P91.6-, P92-,
P96.81), R78.81, R78.89
17 Lack of expected normal
E40- through E46-, E50- through
physiological development (such E63-, P92-, R62- (exclude R62.7),
as delayed milestone, failure to R63.3
gain weight, failure to thrive);
nutritional deficiencies in children
only. Does not include sexual or
Selected Mental Health and Substance Abuse Conditions
mental development. Selected Mental Health
Selected Mental Health and Substance use Conditions
Conditions, Substance Use
Disorders, and Exploitations
18 Alcohol-related disorders
F10-, G62.1, O99.31-
19 Other substance-related disorders F11- through F19- (exclude F17-),
(excluding tobacco use disorders) G62.0, O99.32-
19a Tobacco use disorder
F17-, O99.33-
20a Depression and other mood
F30- through F39-
disorders
20b Anxiety disorders, including post- F06.4, F40- through F42-, F43.0,
traumatic stress disorder (PTSD) F43.1-, F93.0
20c Attention deficit and disruptive F90- through F91-
behavior disorders
20d Other mental disorders, excluding F01- through F09- (exclude
drug or alcohol dependence
F06.4), F20- through F29-, F43-
through F48- (exclude F43.0- and
F43.1-), F50- through F99-
(exclude F55-, F84.2, F90-, F91-,
F93.0, F98-), O99.34-, R45.1,
R45.2, R45.5, R45.6, R45.7,
R45.81, R45.82, R48.0
20e Human trafficking
T74.5- through T74.6-, T76.5-
through T76.6-, Z04.81, Z04.82,
Z62.813, Z91.42
20f Intimate partner violence
T74.11, T74.21, T74.31, Z69.11,
Y07.0-
Number of Visits by Diagnosis Regardless of Primacy (a)
Selected Childhood Conditions (limited to ages 0 thru 17) <blank for demonstration> <blank for demonstration>
<blank for demonstration>
Selected Mental Health and Substance use Conditions
<blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration>
<blank for demonstration>
Number of Patients with Diagnosis (b)
Selected Childhood Conditions (limited to ages 0 thru 17) <blank for demonstration> <blank for demonstration>
<blank for demonstration>
Selected Mental Health and Substance use Conditions <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration>
<blank for demonstration>
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SELECTED SERVICES RENDERED
Line
Selected Diagnostic Tests/Screening/Preventive Services
21
Service Category
Selected Diagnostic Tests/ Screening/Preventive Services HIV test
21a Hepatitis B test
21b Hepatitis C test
21c Novel coronavirus (SARS-CoV-2) diagnostic test
21d Novel coronavirus (SARS-CoV-2) antibody test
21e Pre-Exposure Prophylaxis (PrEP)associated management of all patients on PrEP
22
Mammogram
23
Pap test
24
Selected immunizations: hepatitis A;
haemophilus influenzae B (HiB);
pneumococcal, diphtheria, tetanus,
pertussis (DTaP) (DTP) (DT);
measles, mumps, rubella (MMR);
poliovirus; varicella; hepatitis B
24a Seasonal flu vaccine
Applicable ICD-10-CM, CPT4/I/II/PLA, or HCPCS Code
Selected Diagnostic Tests/Screening/Preventive Services
CPT-4: 86689, 86701 through 86703, 87389 through 87391, 87534 through 87539, 87806 CPT-4: 80074, 86704 through 86707, 87340, 87341, 87350, 87912 CPT-4: 80074, 86803, 86804, 87520 through 87522, 87902 CPT-4: 87426, 87635, 87636, 87637 HCPCS: U0001, U0002, U0003, U0004 CPT PLA: 0202U, 0223U, 0225U, 0240U, 0241U CPT-4: 86328, 86408, 86409, 86769 CPT PLA: 0224U, 0226U CPT-4: 99401 through 99404 ICD-10: Z11.3, Z11.4, Z20.2, Z20.6, Z51.81, Z71.51, Z71.7, Z79.899 Limit to emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) or emtricitabine/tenofovir alafenamide (FTC/TAF) for PrEP CPT-4: 77063, 77065, 77066, 77067 ICD-10: Z12.31 HCPCS: G0279 CPT-4: 88141 through 88153, 88155, 88164 through 88167, 88174, 88175 ICD-10: Z01.41-, Z01.42, Z12.4 (exclude Z01.411 and Z01.419) CPT-4: 90632, 90633, 90634, 90636, 90643, 90644, 90645, 90646, 90647, 90648, 90669, 90670, 90696, 90697, 90698, 90700, 90701, 90702, 90703, 90704, 90705, 90706, 90707, 90708, 90710, 90712, 90713, 90714, 90715, 90716, 90718, 90720, 90721, 90723, 90730, 90731, 90732, 90740, 90743, 90744, 90745, 90746, 90747, 90748 CPT-4: 90630, 90653 through 90657, 90658, 90661, 90662, 90672, 90673, 90674, 90682, 90685 through 90689, 90756
Number of Visits (a)
Selected Diagnostic Tests/Screening/Preventive Services <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration>
<blank for demonstration>
<blank for demonstration>
Number of Patients (b)
Selected Diagnostic Tests/Screening/Preventive Services <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration>
<blank for demonstration>
<blank for demonstration>
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Line 24b
25 26
26a 26b
26c
26d
Service Category Coronavirus (SARS-CoV-2) vaccine
Contraceptive management Health supervision of infant or child (ages 0 through 11)
Childhood lead test screening (9 to 72 months) Screening, Brief Intervention, and Referral to Treatment (SBIRT)
Smoke and tobacco use cessation counseling
Comprehensive and intermediate eye exams
Applicable ICD-10-CM, CPT4/I/II/PLA, or HCPCS Code CPT-I: 0001A-0004A, 0011A0014A, 0021A-0024A, 0031A0034A, 0041A-0044A, 91300, 91301, 91302, 91303, 91304
ICD-10: Z30CPT-4: 99381 through 99383, 99391 through 99393 ICD-10: Z00.1-, Z76.1. Z76.2 ICD-10: Z13.88 CPT-4: 83655 CPT-4: 99408, 99409 HCPCS: G0396, G0397, G0443, H0050
CPT-4: 99406, 99407 HCPCS: S9075 CPT-II: 4000F, 4001F, 4004F CPT-4: 92002, 92004, 92012, 92014
Number of
Visits (a)
<blank for demonstration>
Number of
Patients (b)
<blank for demonstration>
<blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration>
<blank for demonstration>
<blank for demonstration>
<blank for demonstration>
<blank for demonstration>
<blank for demonstration>
<blank for demonstration>
<blank for demonstration>
<blank for demonstration>
Line
Selected Dental Services
27 28
Service Category
Selected Dental Services Emergency services Oral exams
29
Prophylaxis--adult or child
30
Sealants
31
Fluoride treatment--adult or child
32
Restorative services
33
Oral surgery (extractions and other
surgical procedures)
34
Rehabilitative services (Endo, Perio,
Prostho, Ortho)
Applicable ADA Code
Selected Dental Services
CDT: D0140, D9110 CDT: D0120, DO145, D0150, D0160, D0170, D0171, D0180 CDT: D1110, D1120 CDT: D1351 CDT: D1206, D1208 CPT-4: 99188 CDT: D21xx through D29xx CDT: D7xxx
CDT: D3xxx, D4xxx, D5xxx, D6xxx, D8xxx
Number of Visits (a)
Selected Dental Services
<blank for demonstration>
<blank for demonstration>
Number of Patients (b)
Selected Dental Services
<blank for demonstration>
<blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration>
<blank for demonstration> <blank for demonstration>
<blank for demonstration>
<blank for demonstration>
Notes: Sources of Codes:
· ICD-10-CM (2021)National Center for Health Statistics (NCHS)
· CPT (2021)American Medical Association (AMA)
· Code on Dental Procedures and Nomenclature CDT Code (2021)Dental Procedure Codes. American Dental Association (ADA)
"X" in a code: Denotes any number, including the absence of a number in that place. Dashes (-) in a code indicate that additional characters are required. ICD-10-CM codes all have at least four digits. These codes are not intended to reflect whether or not a code is billable. Instead, they are used to point out that other codes in the series are to be considered.
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UDS SUPPORT CENTER, 866-UDS-HELP, UDSHELP330@BPHCDATA.NET Table 6A Cross-Table Considerations: · The count of patients by diagnosis reported on Table 6A will not be the same count as on Tables 6B and 7,
due to differences in criteria that must be met for inclusion on Tables 6B or 7. · If you submit Grant Reports, the total number of patients and visits reported on the grant table must be less
than or equal to the corresponding number on the Universal Report for each cell.
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Instructions for Tables 6B and 7
Tables 6B and 7 collect data on selected quality of care and clinical health outcome and disparity measures. BPHC first implemented these measures in 2008 and continues to update them. BPHC will continue to revise and expand these measures consistent with the National Quality Strategy, CMS electronic Clinical Quality Measures (eCQMs), and other national quality initiatives.
The clinical quality measures (CQMs) described in this manual must be reported by all health centers using specifications detailed in the measure definitions described below. The majority of the UDS clinical quality measures are aligned with CMS 2021 Performance Period Eligible Professional/Eligible Clinical eCQMs. Use the most current CMS-issued eCQM specifications for the eCQM number and version referenced in the UDS Manual for 2021 reporting and measurement period. Although there are other year and version updates available from CMS, they are not to be used for 2021 reporting.
Note: The phrase "measurement period" used in this section is intended to represent calendar year 2021 unless another timeframe is specifically noted.
For UDS clinical quality measure reporting, include and evaluate patients for the denominator who had at least one medical visit during the measurement period as specified in the measure (dental visits during the measurement period are used for the dental sealant measure), even though some eCQMs may specify a broader range of service codes (e.g., mental health, substance use disorder).
The measure specifications can be found at the CMS Electronic Clinical Quality Improvement (eCQI) Resource Center.10 The eCQM measure numbers and links are provided to assist you, when applicable. Further clarification or interpretation of CMS eCQMs may be provided by the measure steward (listed in Appendix G). Additionally, the use of official versions of vocabulary value sets as contained in the Value Set Authority Center (VSAC)11 is encouraged for health centers capable of appropriately using this resource as defined to support the data reporting of these clinical quality measures.
Note: CMS uses logic statements describing the criteria for eCQM reporting using Clinical Quality Language (CQL) in an effort to standardize reporting workflows. Health centers are advised to review workflows and to work with HIT/EHR vendors and IT personnel to ensure that required data are being captured correctly to calculate measures.
COLUMN LOGIC INSTRUCTIONS
Column A (A, 2A, or 3A): Number of Patients in the Denominator
· Report the total number of patients who fulfill the detailed criteria described for the specified measure. · Report all patients meeting the criteria in the health center's denominator, including all sites (e.g., urgent care,
prenatal), all in-scope programs (e.g., targeted programs, special populations), and all providers.
10 Simplified coding and billing requirements for evaluation and management visits went into effect January 1, 2021. More information is available from the American Medical Association's CPT Evaluation and Management Code and Guideline Changes document. 11 Requires free user account and login.
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Because the denominator for each measure is defined in whole or in part in terms of age (or age and sex assigned at birth), comparisons to the numbers on Tables 3A, 6B, and 7 will be made when evaluating your submission. The numbers in Column A of Tables 6B and 7 will not be equal to those that might be calculated on Table 3A for the following reasons:
(1) All patients seen for reportable services (i.e., medical, dental, mental health) are counted on Table 3A, but only patients seen for medical care (or dental for the one dental measure) are considered for the clinical quality measures reported on Tables 6B and 7. The more dental-, mental health-, or substance use disorderonly patients a health center has, the less comparable the data will be. (2) Table 3A measures age as of June 30 of the calendar year, but Tables 6B and 7 define other time periods (e.g., as of January 1) to measure age. Although comparisons may be made between the numbers on Table 6A and Tables 6B and 7, the numbers in Column A of Tables 6B and 7 will not be equal to those reported in Column B of Table 6A for the following reasons:
(1) All patients, regardless of age, seen for all reportable services and diagnoses, are included on Table 6A, but Tables 6B and 7 relate only to patients of specific age ranges. (2) Table 6A reflects diagnoses and services during the calendar year, but in Tables 6B and 7 measures may require patients to be considered based on active diagnoses or a look-back period of completed services. Additionally, birth outcomes on Table 7 are compared to prenatal care patients on Table 6B.
Column B (B, 2B, or 3B): Number of Charts/Records Sampled or EHR Total
· Report the total number of health center patients from the denominator (Column A) for whom data have been reviewed. The number will essentially become the denominator in evaluating the numerator criteria and will be: o all patients who fit the criteria (the same number as the denominator reported in Column A), or o a number equal to or greater than 80 percent12 of all patients who meet the criteria (a value no less than 80 percent of the denominator reported in Column A), or o a scientifically drawn random sample of 70 patient charts selected from all patients who fit the criteria. Please refer to Appendix C for specifics on sampling methodology.
If a sample is to be used, it must be a random sample of 70 patient charts and must be drawn from the health center's entire patient population during the measurement period identified as belonging in the denominator. Larger samples will not be accepted. Health centers may not choose to select the same number of charts from each site or the same number for each provider or use other stratification mechanisms because this will result in oversampling some group of patients.
12 To streamline the process for reporting on the CQMs, and to encourage the use of HIT to report on the full denominator of patients, health centers may use all of the records available in the HIT/EHR for any given clinical quality measure in lieu of a chart sample if at least 80 percent of all health center patients' health records are included in the HIT/EHR and the patients missing from the HIT/EHR are not related to any target group or variable involved with that given measure. For example, if the patients from a pediatric service delivery site are missing in the HIT/EHR, it cannot be used for the childhood immunization measure.
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Use a review of a sample of charts in lieu of full-denominator reporting from an HIT/EHR for any given clinical quality measure if:
· the HIT/EHR system does not include a minimum of 80 percent of health center patients who meet the criteria described below for inclusion in the specific measure's denominator,
· the HIT/EHR system does not exclude every health center patient who meets one or more exclusion criteria described below for exclusion from the denominator,
· the HIT/EHR system has not been in place long enough to be able to find the data required in prior year's activities (look-back period data are necessary for many of the UDS CQMs [e.g., cervical cancer screening, colorectal cancer screening, childhood immunizations]), or
· the required data were not collected from the patient as part of the visit or searchable in discrete data fields at the time of the visit.
Records for new patients should be obtained from their former providers to document prior treatment, including data for look-back periods. Patient health records obtained from other providers may be recorded in the health center's HIT/EHR system consistent with internal patient health records policies, at which point they may be used in the calculated performance rate for the applicable measure.
If the HIT/EHR system is used, the number in Column B (records reviewed) must be no less than 80 percent of the number in Column A when the total denominator is greater than 70. The reduced total (in Column B) may not be the result of excluding patients based on a variable related to the measure.
Column C (C or 2C) or 3F: Number of Charts/Records Meeting the Numerator Criteria
· Report the total number of records (included in the count for Column B) that meet the numerator criteria for the specified clinical quality measure. The number in Column C or F (records in the numerator) can never exceed the number in Column B (patient health records reviewed).
Note: The percentage of patient health records meeting the numerator criteria can be calculated by dividing Column C or 3F by Column B.
Criteria vs. Exceptions and Exclusions in HITs/EHRs vs. Chart Reviews
In the information that follows, "conditions" or "criteria" are at times used interchangeably as "exceptions" or "exclusions." This is partly because of the differing language and procedures in an HIT/EHR (or practice management system)-based report versus a chart audit report. In an HIT/EHR or PMS review, all criteria for a measure must be locatable in the HIT/EHR and must be in the HIT/EHR for each patient at the health center. If they cannot be found, findings will be distorted and the HIT/EHR cannot be used. It is important that the HIT/EHR differentiates between medical and dental patients and is able to limit to either medical or dental patients as specified in each CQM.
In a sample chart review process, items listed as "criteria" may be used as "exclusions." In cases where the sample includes a dental-only patient for a CQM that should include medical patients in the denominator, replace the dental-only patient with another medical patient.
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And vs. Or
In this section, conditions linked with "and" mean that each of the conditions must be met. If some but not all conditions are met, the services for that patient are considered to have failed to meet the numerator criteria. Conditions linked with "or" mean that criteria must be evaluated in the order prescribed by the measure steward statements. For example, if the first statement is not met, move to the second, then the third, etc.
DETAILED INSTRUCTIONS FOR CLINICAL QUALITY MEASURES
The clinical quality measures (CQMs) reported in the UDS relate only to medical patients (or only to dental patients in the case of one dental measure). Report each measure using the criteria outlined below. Each measure has been organized in the same way to assist with data collection and reporting. · Measure Description: The quantifiable indicator to be evaluated. · Denominator: Patients who fit the detailed criteria described for inclusion in the specific measure to be
evaluated. · Numerator: Records (from the denominator) that meet the criteria for the specified measure. · Denominator Exclusions: Patients not to be considered for the measure and who should be removed from
the denominator before determining if numerator criteria are met. · Denominator Exceptions: Patients removed from the denominator because numerator criteria are not met. · Specification Guidance: CMS measure guidance that assists with understanding and implementing eCQMs. · UDS Reporting Considerations: Additional BPHC requirements and guidance that must be applied to the
specific measure and that may differ from or expand on the eCQM specifications.
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Instructions for Table 6B: Quality of Care Measures
The quality-of-care measures reported on Table 6B are "process measures." This means they document services that have been shown to be correlated with and serve as a proxy for positive long-term health outcomes. Individuals who receive routine preventive care and timely chronic care are more likely to have positive outcomes.
Several notable changes have been made to Table 6B, as outlined below:
· The specifications for the clinical quality measures reported have been revised to align with the CMS eCQMs. The clinical quality measures are aligned with the most current eCQMs for Eligible Professionals for the 2021 version number referenced in the UDS Manual for the measurement period. (Other updates are available, but they should not be used for the 2021 reporting.)
· The Cervical Cancer Screening measure has removed the cervical cytology requirement for women age 30 and older (HPV test remains).
· The Tobacco Screening measure numerator changed from a 24-month to a 12-month requirement.
TABLE 6B: QUALITY OF CARE MEASURES
This table specifically includes the following CQMs:
Screening and Preventive Care · Cervical Cancer Screening
Maternal Care and Children's Health · Early Entry into Prenatal Care
· Breast Cancer Screening
· Childhood Immunization Status
Disease Management
· Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
· Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
· Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
· Colorectal Cancer Screening
· Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
· Dental Sealants for Children between 69 Years
· Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
· HIV Linkage to Care
· Depression Remission at Twelve Months
· HIV Screening
· Preventive Care and Screening: Screening for Depression and Follow-Up Plan
SECTIONS A AND B: DEMOGRAPHIC CHARACTERISTICS OF PRENATAL CARE PATIENTS
This section includes information about patients in the prenatal care program.
· Report on all patients who are either provided direct prenatal care or referred for prenatal care.
· Report on the age and trimester of entry into prenatal care for all prenatal care patients, regardless of whether they receive all or some of their prenatal services in the health center or are referred elsewhere.
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· DO NOT include patients who had a positive pregnancy test but did not initiate prenatal care with the health center or its referral network.
· DO NOT include patients who did not receive prenatal care from a health center provider or who were not referred by the health center to another provider for prenatal care.
· DO NOT include patients who chose to receive all their prenatal care outside of the health center's referral network.
· DO NOT include pregnant patients who received care unrelated to their pregnancy and who are being seen elsewhere for prenatal care.
Prenatal Care by Referral Only (check box)
All health centers are required to provide prenatal care to patients, either directly or by referral. · Check the "Prenatal Care by Referral Only" check box if you provide prenatal care to patients only through
direct referral to another provider. · DO NOT select this flag if your health center providers provide some or all prenatal care to patients directly.
Section A: Age of Prenatal Care Patients (Lines 16)
· Report the total number of patients by age group who received prenatal care during the calendar year from the health center or from a provider in your referral network. Include all patients receiving any prenatal care, including the delivery of their child, during the calendar year, regardless of when that care was initiated.
· Include patients who: o receive all their prenatal care from the health center, o were referred by the health center to another provider for all their prenatal care, o began prenatal care with another provider but transferred to the health center at some point during their prenatal care, o began prenatal care with the health center but were transferred to another provider at some point during their prenatal care, o were provided with all their prenatal care by a health center provider but were delivered by another provider, o began or were referred for care during the previous calendar year or in this calendar year and delivered during the calendar year, or o began or were referred for their care in this calendar year but will not or did not deliver until the next year.
· To determine the appropriate age group, use the patient's age on June 30 of the calendar year. Note: As many as half of all prenatal care patients reported will usually have been reported in the prior year or will be reported in the next year.
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Section B: Early Entry into Prenatal Care (Lines 79), No eCQM
Measure Description Percentage of prenatal care patients who entered prenatal care during their first trimester. Calculate as follows: Denominator: Line 7 + Line 8 + Line 9, Columns A + B · Patients seen for prenatal care during the year Numerator: Line 7, Columns A + B · Patients who began prenatal care at the health center or with a referral provider (Column A), or who began
care with another prenatal provider (Column B), during their first trimester Exclusions/Exceptions · Denominator Exclusions
o Not applicable · Denominator Exceptions
o Not applicable Specification Guidance · Not applicable UDS Reporting Considerations · Report on Lines 79 all patients who received prenatal care, either directly or through a referral, including but
not limited to the delivery of a baby during the calendar year. o First Trimester (Line 7): Report patients who were prenatal care patients during the reporting period and
whose first visit occurred when they were estimated to be pregnant up through the end of the 13th week after the first day of their last menstrual period. o Second Trimester (Line 8): Report patients who were prenatal care patients during the reporting period whose first visit occurred when they were estimated to be between the start of the 14th week and the end of the 27th week after the first day of their last menstrual period. o Third Trimester (Line 9): Report patients who were prenatal care patients during the reporting period and whose first visit occurred when they were estimated to be 28 weeks or more after the first day of their last menstrual period. Note: It is unusual for the number in Column B to be very large or larger than that in Column A. This is especially true for the third trimester, because it would require patients to have begun care very late and then transfer to the health center in a very short period of time. The sum of the numbers in the six cells of Lines 7 through 9 represents the total number of patients who received prenatal care from the health center during the calendar year and is equal to the number reported on Line 6.
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· Use the following criteria to identify how prenatal care patients are reported: o Only report patients who had their first comprehensive prenatal exam with the health center or with the referral provider as having begun prenatal care. Health center visits that include pregnancy and other lab tests, dispensing vitamins, taking a health history, and/or obtaining a nutritional or psychosocial assessment only DO NOT count as the start of prenatal care. o Determine the trimester by the trimester of pregnancy that the patient was in when they began prenatal care either at one of the health center's service delivery locations or with another provider, including a referral provider. o Report a patient who begins prenatal care with the health center or is referred by the health center to another provider only once in Column A (not Column B). o Report a patient who begins prenatal care on their own with another provider and then transfers to the health center only once in Column B (not in Column A). o Patient self-report of trimester of entry is permitted. o Report the patient twice as a prenatal care patient in those rare instances when a patient receives prenatal care services for two separate pregnancies in the same calendar year.
SECTIONS C THROUGH M: OTHER QUALITY OF CARE MEASURES
In these sections, report on the findings of your reviews of services provided to targeted populations. · For sections C through L, specifically assess the current medical patients (i.e., patients who had a medical
visit at least once during the measurement period). DO NOT include patients whose only visits were for dental, mental health, or something other than medical care in the denominator for these measures. · For section M, assess current dental patients (i.e., patients who had a dental visit at least once during the measurement period). DO NOT include patients whose only visits were for medical, mental health, or something other than dental care in the denominator for this measure. · For these measures, calculate age using the specified dates as required for each eCQM. Age is generally the patient's age prior to the start of January 1 of the calendar year. · Using the specified criteria, include patients seen for medical care even if the only care provided was in an urgent care setting, if patients were seen only once for acute care, if patients were seen only for specialty care, or if the patient has since left the practice. · For measures requiring the completion of screenings, tests, or procedures to meet the numerator criteria, the findings of the screenings, test results, or procedures must be documented in the patient health record. Note: In this section, the term "measurement period" is the timeframe specified by the measure steward. For measures not electronically specified, this is intended to capture calendar year 2021 data.
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Childhood Immunization Status (Line 10), CMS117v9
Measure Description
Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three or four H influenza type B (HiB); three Hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one Hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.
Calculate as follows:
Denominator: Columns A and B
· Children who turn 2 years of age during the measurement period and who had a medical visit during the measurement period
Note: Include children with birthdate on or after January 1, 2019, children with birthdate on or before December 31, 2019, and make sure the data is reflective of children who turn 2 during the measurement period.
Numerator: Column C
· Children who have evidence showing they received recommended vaccines, had documented history of the illness, had a seropositive test result, or had an allergic reaction to the vaccine by their second birthday
Exclusions/Exceptions
· Denominator Exclusions o Patients who were in hospice care during the measurement period
· Denominator Exceptions o Not applicable
Specification Guidance
· Include patients in the numerator in these situations: o MMR, Hep B, VZV, and Hep A vaccines: evidence of receipt of the recommended vaccine, documented history of the illness, or a seropositive test result for the antigen o DTaP, IPV, HiB, pneumococcal conjugate, rotavirus, and influenza vaccines: evidence of receipt of the recommended vaccine. o For a particular antigen: patients who had an anaphylactic reaction or adverse reaction to the vaccine o For DTaP vaccine: patients who have encephalopathy o For IPV vaccine: patients who have had an anaphylactic reaction to streptomycin, polymyxin B, or neomycin o For Influenza, MMR, or VZV vaccines: if patients have cancer of lymphoreticular or histiocytic tissue, multiple myeloma, or leukemia; have had an anaphylactic reaction to neomycin; have immunodeficiency or have HIV o For Hep B vaccine: patients who have had an anaphylactic reaction to common baker's yeast
· The measure allows a grace period by measuring numerator criteria with these recommendations between birth and age 2.
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UDS Reporting Considerations
· Include children who turned 2 years of age during the measurement period, regardless of when they were seen for medical care during the year. Specifically, include them in the assessment whether the medical visit in the year occurred before or after they turned 2.
· Include children in the denominator if they came to the health center for well-child13 services or for any other medical visits, including treatment of an injury or illness.
· Include children in the denominator for whom no vaccination information is available and/or who were first seen at a point when there was not enough time to fully immunize them prior to their second birthday.
· Include children who had a contraindication for a specific vaccine in the denominator. Count them as being "compliant" for that specific vaccine, if the guidance (Specification Guidance) permits it, and then review for the administration of the rest of the vaccines.
· To meet the numerator criteria, a child's health record must be documented as being compliant for each vaccine.
· Registries can be used to fill any voids in the immunization record if the search is routinely done prior to or immediately after a visit and before the end of the measurement period. For example, you may use an immunization registry maintained by the state or other public entity that shows comparable information.
· Do not include patients here or anywhere on the UDS who only received a vaccination and never received other services.
· Do not count as meeting the numerator criteria charts that only state that the "patient is up to date" with all immunizations and that DO NOT list the dates of all immunizations and the names of immunization agents.
· DO NOT count toward the numerator criteria verbal assurance from a parent or other individual that a vaccine has been given.
· Good-faith efforts to get a child immunized that fail DO NOT meet the numerator criteria. These include the following: o Parental failure to bring in the patient o Parents who refuse due to personal beliefs about vaccines or for religious reasons o Patients lost to follow-up
Cervical Cancer Screening (Line 11), CMS124v9
Measure Description
Percentage of women 21*64 years of age who were screened for cervical cancer using either of the following criteria:
· Women age 21*64 who had cervical cytology performed within the last 3 years · Women age 3064 who had human papillomavirus (HPV) testing performed within the last 5 years Note: *Use 23 as the initial age to include in assessment. See Specification Guidance for further detail.
13 Health centers should add to their denominator those patients whose only visits were well-child visits (99381, 99382, 99391, 99392) if their automated system does not include them. In addition, if your state uses different codes for EPSDT visits, those codes should be added.
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Calculate as follows: Denominator: Columns A and B · Women 23 through 63 years of age with a medical visit during the measurement period Note: Include women with birthdate on or after January 2, 1957, and birthdate on or before January 1, 1998. Numerator: Column C · Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the
following criteria: o Cervical cytology performed during the measurement period or the 2 years prior to the measurement
period for women who are at least 21 years old at the time of the test. o Cervical HPV testing performed during the measurement period or the 4 years prior to the measurement
period for women who are 30 years or older at the time of the test. Exclusions/Exceptions · Denominator Exclusions
o Women who had a hysterectomy with no residual cervix or a congenital absence of cervix o Women who were in hospice care during the measurement period · Denominator Exceptions o Not applicable Specification Guidance · The measure only evaluates whether tests were performed after a woman turned 21 years of age. The youngest age in the initial population is 23. UDS Reporting Considerations · Include documentation in the patient health record of a cervical cytology and HPV tests performed outside of the health center with the date the test was performed, who performed it, and the result of the finding provided by the agency that conducted the test or a copy of the lab test. · Include patients of all genders who have a cervix. · If a system cannot determine exclusions, include them in the denominator and later exclude and replace them from the sample, if identified. · DO NOT count as compliant charts that note the refusal of the patient to have the test.
Breast Cancer Screening (Line 11a), CMS125v9
Measure Description Percentage of women 50*74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period Note: *Use 51 as the initial age to include in assessment. See UDS Reporting Considerations for further detail.
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Calculate as follows: Denominator: Columns A and B · Women 51 through 73 years of age with a medical visit during the measurement period Note: Include women with birthdate on or after January 2, 1947, and birthdate on or before January 1, 1970. Numerator: Column C · Women with one or more mammograms during the 27 months prior to the end of the measurement period Exclusions/Exceptions · Denominator Exclusions
o Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy or for whom there is evidence of a right and a left unilateral mastectomy
o Patients who were in hospice care during the measurement period o Patients aged 66 or older who were living long-term in an institution for more than 90 days during the
measurement period o Patients aged 66 and older with advanced illness and frailty · Denominator Exceptions o Not applicable Specification Guidance · The measure evaluates primary screening. · DO NOT count biopsies, breast ultrasounds, or magnetic resonance imaging, because they are not appropriate methods for primary breast cancer screening. UDS Reporting Considerations · The measure only evaluates whether tests were performed after a woman turned 50 years of age. The youngest age in the initial population is 51. · If a mammogram was performed outside of the health center, include documentation in the patient health record with the date the test was performed, who performed it, and the result of the finding provided by the agency that conducted the diagnostic study or a copy of the results. · If a system cannot determine exclusions, include them in the denominator and later exclude and replace them from the sample, if identified. · Include patients according to sex at birth. · DO NOT count as compliant charts that note the refusal of the patient to have the test.
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Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (Line 12), CMS155v9
Measure Description
Percentage of patients 317* years of age who had an outpatient medical visit and who had evidence of height, weight, and body mass index (BMI) percentile documentation and who had documentation of counseling for nutrition and who had documentation of counseling for physical activity during the measurement period
Note: *Use 16 as the final age at the start of the measurement period to include in assessment.
Calculate as follows:
Denominator: Columns A and B
· Patients 3 through 16 years of age with at least one outpatient medical visit during the measurement period Note: Include children and adolescents with birthdate on or after January 2, 2004, and birthdate on or before January 1, 2018.
Numerator: Column C
· Children and adolescents who have had: o their height, weight, and BMI percentile recorded during the measurement period and o counseling for nutrition during the measurement period and o counseling for physical activity during the measurement period
Exclusions/Exceptions
· Denominator Exclusions o Patients who have a diagnosis of pregnancy during the measurement period o Patients who were in hospice care during the measurement period
· Denominator Exceptions o Not applicable
Specification Guidance
· Because BMI norms for youth vary with age and sex, this measure evaluates whether BMI percentile is assessed rather than an absolute BMI value.
UDS Reporting Considerations
· Include medical visits performed by any medical provider. Note that this is different from the eCQM, which requires that the visit be performed by a primary care physician or an OB/GYN. For example, include patients who had a medical visit with an NP.
· The UDS numerator differs from the eCQM in that the eCQM requires the numerator elements to be reported separately against two age strata (age 311, age 1216). For UDS purposes, the patients must have had all three numerator components completed in order to meet the numerator criteria using one age strata (age 3 16).
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· DO NOT count as meeting the numerator criteria charts that show only that a well-child visit was scheduled, provided, or billed. The electronic or paper well-child visit template/form must document each of the elements noted above.
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan (Line 13), CMS69v9
Measure Description Percentage of patients aged 18 years and older with BMI documented during the most recent visit or within the previous 12 months to that visit and who had a follow-up plan documented if the most recent BMI was outside of normal parameters Note: Normal parameters: For age 18 years and older, BMI greater than or equal to 18.5 and less than 25 kg/m2 Calculate as follows: Denominator: Columns A and B
· Patients 18 years of age or older on the date of the visit with at least one medical visit during the measurement period
Note: Include patients with birthdate between January 1, 2003, and December 31, 2003, or earlier, who were 18 years of age or older on the date of their last visit. Numerator: Column C · Patients with:
o a documented BMI (not just height and weight) during their most recent visit in the measurement period or during the previous 12 months of that visit, and
o when the BMI is outside of normal parameters, a follow-up plan is documented during the visit or during the previous 12 months of the current visit
Note: Include in the numerator patients within normal parameters who had their BMI documented and those with a follow-up plan if BMI is outside normal parameters. Exclusions/Exceptions · Denominator Exclusions
o Patients who are pregnant during the measurement period o Patients receiving palliative or hospice care during or prior to the visit · Denominator Exceptions o Patients who refuse measurement of height and/or weight o Patients with a documented medical reason (see Specification Guidance) o Patients in an urgent or emergent medical situation where time is of the essence and to delay treatment
would jeopardize the patient's health status
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Specification Guidance · Report this measure for all patients seen during the reporting period. · An eligible professional or their personnel is required to measure both height and weight. Both height and
weight must be measured within 12 months of the current encounter and may be obtained from separate visits. · BMI may be documented in the patient health record at the health center or in outside patient health records
obtained by the health center. · If more than one BMI is reported during the measurement period, use the most recent BMI to determine if the
numerator criteria has been met. · Document the follow-up plan based on the most recent documented BMI outside of normal parameters. · Documented medical reasons include, but are not limited to:
o Elderly patients (65 years or older) for whom weight reduction or gain would complicate other underlying health conditions, such as the following examples: Illness or physical disability Mental illness, dementia, confusion Nutritional deficiency, such as vitamin or mineral deficiency
· DO NOT use self-reported height and weight values. UDS Reporting Considerations · Documentation in the patient health record must show the actual BMI, or the template normally viewed by a
provider must display BMI. · DO NOT count as meeting the numerator criteria charts or templates that display only height and weight. The
fact that an HIT/EHR can calculate BMI does not replace the presence of the BMI itself. · DO NOT include patients who only had virtual visits during the year in the assessment of this measure.
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (Line 14a), CMS138v9
Measure Description Percentage of patients aged 18 and older who were screened for tobacco use one or more times within 12 months and who received tobacco cessation intervention if identified as a tobacco user Calculate as follows: Denominator: Columns A and B · Patients aged 18 years and older seen for at least two medical visits in the measurement period or at least one
preventive medical visit during the measurement period. Note: Include patients with birthdate on or before January 1, 2003.
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Numerator: Column C
· Patients who were screened for tobacco use at least once within 12 months before the end of the measurement period and
· Who received tobacco cessation intervention if identified as a tobacco user Note: Include in the numerator patients with a negative screening and those with a positive screening who had cessation intervention if a tobacco user.
Exclusions/Exceptions
· Denominator Exclusions o Not applicable
· Denominator Exceptions o Documentation of medical reason(s) for not screening for tobacco use or for not providing tobacco cessation intervention (e.g., limited life expectancy, other medical reason)
Specification Guidance
· If patients use any type of tobacco (i.e., smokes or uses smokeless tobacco), tobacco cessation intervention (counseling and/or pharmacotherapy) is expected.
· In order to promote a team-based approach to patient care, the tobacco cessation intervention can be performed by another health care provider; therefore, the tobacco use screening and tobacco cessation intervention DO NOT need to be performed by the same provider.
· If a patient has multiple tobacco use screenings during the 12-month period, use the most recent screening that has a documented status of tobacco user or non-user.
· If tobacco use status of a patient is unknown, the patient does not meet the screening component required to be counted in the numerator and has not met the numerator criteria. "Unknown" includes patients who were not screened or patients with indefinite answers.
· If the patient does not meet the screening component of the numerator but has an allowable medical exception, remove the patient from the denominator.
· The medical reason exception applies to the screening data element of the measure or to any of the tobacco cessation intervention (counseling and/or pharmacotherapy) data elements.
· If a patient has a diagnosis of limited life expectancy, that patient has a valid denominator exception for not being screened for tobacco use or for not receiving tobacco use cessation intervention (counseling and/or pharmacotherapy) if identified as a tobacco user.
· Electronic nicotine delivery systems (ENDS), including electronic cigarettes for tobacco cessation, are not currently classified as tobacco. They are not evaluated for this measure.
UDS Reporting Considerations
· Report in the numerator records that demonstrate that the patient had been asked about their use of all forms of tobacco within 12 months before the end of the measurement period.
· Cessation counseling intervention for a tobacco user must occur at or following the most recent screening and before the end of the calendar year. If the cessation intervention is pharmacotherapy, then the prescription must be active (one that has not expired).
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· Include patients who receive tobacco cessation intervention by any provider, including those who: o received tobacco use cessation counseling services, or o received an order for (a prescription or a recommendation to purchase an over-the-counter [OTC] product) a tobacco use cessation medication, or o are on (using) a tobacco use cessation agent.
· Identify preventive visits using "Preventive Care Services" CPT codes referenced in the eCQM. · The UDS denominator differs from the eCQM in that the eCQM requires the patient population and
numerator to be reported separately; for UDS purposes, the patients must be evaluated as one group. · DO NOT count as meeting the numerator criteria providing written self-help materials only.
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease (Line 17a), CMS347v4
Measure Description Percentage of the following patients at high risk of cardiovascular events aged 21 years and older who were prescribed or were on statin therapy during the measurement period: · Patients 21 years of age or older who were previously diagnosed with or currently have an active diagnosis of
clinical atherosclerotic cardiovascular disease (ASCVD), or · Patients 21 years of age or older who have ever had a fasting or direct low-density lipoprotein cholesterol
(LDL-C) level greater than or equal to 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia, or · Patients 40 through 75 years of age with a diagnosis of diabetes with a fasting or direct LDL-C level of 70 189 mg/dL Calculate as follows: Denominator: Columns A and B · Patients 21 years of age and older who: o have an active diagnosis of ASCVD or o ever had a fasting or direct laboratory result of LDL-C greater than or equal to 190 mg/dL or o were previously diagnosed with or currently have an active diagnosis of familial or pure
hypercholesterolemia, or · Patients 40 through 75 years of age with Type 1 or Type 2 diabetes and with an LDL-C result of 70189
mg/dL recorded as the highest fasting or direct laboratory test result in the calendar year or the 2 years prior; · With a medical visit during the measurement period Note: Include patients with birthdate on or before January 1, 2000.
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Numerator: Column C
· Patients who are actively using or who received an order (prescription) for statin therapy at any point during the measurement period
Exclusions/Exceptions
· Denominator Exclusions o Patients who have a diagnosis of pregnancy o Patients who are breastfeeding o Patients who have a diagnosis of rhabdomyolysis
· Denominator Exceptions o Patients with adverse effect, allergy, or intolerance to statin medication o Patients who are receiving palliative care o Patients with active liver disease or hepatic disease or insufficiency o Patients with end-stage renal disease (ESRD) o Patients 40 through 75 years of age with diabetes whose most recent fasting or direct LDL-C laboratory test result was less than 70 mg/dL and who are not taking statin therapy
Specification Guidance
· Current statin therapy (including statin medication samples provided to patients) must be ordered during the measurement period.
· Ensure patients are not counted in the denominator more than once. Once a patient meets one set of denominator criteria (check from first listed in Measure Description to last), they are included and further risk checks are not needed.
· Intensity of statin therapy or lifestyle modification coaching is not being assessed for this measure; only prescription of any statin therapy is being assessed.
· DO NOT count other cholesterol-lowering medications as meeting the numerator criteria; only statin therapy meets the numerator criteria.
UDS Reporting Considerations
· Not applicable
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet (Line 18), CMS164v7
Measure Description
Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), or who had a coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCIs) in the 12 months prior to the measurement period or who had an active diagnosis of IVD during the measurement period, and who had documented use of aspirin or another antiplatelet during the measurement period
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Calculate as follows: Denominator: Columns A and B · Patients 18 years of age and older with a medical visit during the measurement period who had an AMI,
CABG, or PCI during the 12 months prior to the measurement period or who had a diagnosis of IVD overlapping the measurement period Note: Include patients with birthdate on or before January 1, 2003. Numerator: Column C · Patients who had an active medication of aspirin or another antiplatelet during the measurement period Exclusions/Exceptions · Denominator Exclusions o Patients who had documentation of use of anticoagulant medications overlapping the measurement period o Patients who were in hospice care during the measurement period · Denominator Exceptions o Not applicable Specification Guidance · Not applicable UDS Reporting Considerations · Include in the numerator patients who received a prescription for, were given, or were using aspirin or another antiplatelet drug. · The electronic specifications for this measure have not been updated. Follow the CMS164v7 specifications for UDS reporting.
Colorectal Cancer Screening (Line 19), CMS130v9
Measure Description Percentage of adults 5075 years of age who had appropriate screening for colorectal cancer Calculate as follows: Denominator: Columns A and B · Patients 50 through 74 years of age with a medical visit during the measurement period Note: Include patients with birthdate on or after January 2, 1946, and birthdate on or before January 1, 1971.
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Numerator: Column C
· Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria: o Fecal occult blood test (FOBT) during the measurement period o Fecal immunochemical test (FIT)-deoxyribonucleic acid (DNA) during the measurement period or the 2 years prior to the measurement period o Flexible sigmoidoscopy during the measurement period or the 4 years prior to the measurement period o Computerized tomography (CT) colonography during the measurement period or the 4 years prior to the measurement period o Colonoscopy during the measurement period or the 9 years prior to the measurement period
Exclusions/Exceptions
· Denominator Exclusions o Patients with a diagnosis of colorectal cancer or a history of total colectomy o Patients who were in hospice care during the measurement period o Patients aged 66 or older who were living long-term in an institution for more than 90 days during the measurement period o Patients aged 66 and older with advanced illness and frailty
· Denominator Exceptions o Not applicable
Specification Guidance
· DO NOT count digital rectal exam (DRE) or FOBT tests performed in an office setting or performed on a sample collected via DRE.
UDS Reporting Considerations
· There are two FOBT test options: Guaiac fecal occult blood test (gFOBT) and the immunochemical-based fecal occult blood test (iFOBT).
· Lab tests (FOBT and FIT-DNA) performed elsewhere must be confirmed by documentation in the chart: either a copy of the test results or correspondence between the clinic personnel and the performing lab/provider showing the results.
· FOBTs can be used to document meeting the numerator criteria. This test, if performed, is required each measurement period. For example, a patient who had an FOBT in November 2020 would still need one in 2021.
· Collect stool specimens for FOBT and FIT-DNA, as recommended by the manufacturer. · FOBT and FIT-DNA test kits can be mailed to patients, but receipt, processing, and documentation of the test
sample is required. · DO NOT use self-reported test results.
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HIV Linkage to Care (Line 20), No eCQM
Measure Description
Percentage of patients newly diagnosed with HIV who were seen for follow-up treatment within 30 days of diagnosis14
Calculate as follows:
Denominator: Columns A and B
· Patients first diagnosed with HIV by the health center between December 1 of the prior year through November 30 of the current measurement period and who had at least one medical visit during the measurement period or prior year
Note: Include patients who were diagnosed with HIV for the first time ever15 by the health center between December 1, 2020, and November 30, 2021,16 and had at least one medical visit during 2021 or 2020.
Numerator: Column C
· Newly diagnosed HIV patients that received treatment within 30 days of diagnosis. Include patients who were newly diagnosed by your health center providers and: o had a medical visit with your health center provider who initiates treatment for HIV, or o had a visit with a referral resource who initiates treatment for HIV.
Exclusions/Exceptions
· Denominator Exclusions o Not applicable
· Denominator Exceptions o Not applicable
Specification Guidance
· Not applicable UDS Reporting Considerations
· Treatment must be initiated within 30 days of the HIV diagnosis (not just a referral made, education provided, or retest at a referral site).
· Include patients in the numerator only if they received treatment for HIV care within 30 days of the diagnosis. · If the treatment is by referral to another provider or organization (such as a Ryan White provider), the medical
treatment at the referral source must begin during the 30-day period. Documentation that the visit was completed (from the provider to whom the patient was referred) is required. · Identification of patients for this measure crosses years and may include prior-year patients.
14 Note that this measure does not conform to the calendar year reporting requirement. 15 "Patients first diagnosed with HIV" is defined as patients without a previous HIV diagnosis who received a reactive initial HIV test confirmed by a positive supplemental antibody immunoassay HIV test. 16 Because the measure allows up to 30 days to complete the follow-up, look back 30 days to find the entire denominator of patients who should have had a follow-up during the measurement period.
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· Reactive initial HIV tests and patients who self-identify as being HIV positive without documentation must be followed by a supplemental test to confirm diagnosis.
· DO NOT include patients who: o Were diagnosed elsewhere, even if they can provide documentation of the positive test result o Had a positive reactive initial screening test but not a positive supplemental test o Were positive on an initial screening test provided by you but were then sent to another provider for definitive testing and treatment
Note: There are no ICD-10-CM or CPT codes to identify newly diagnosed HIV patients. It is strongly encouraged that you modify your HIT/EHR to record this information or keep track of the patients who are identified in a separate system.
HIV Screening (Line 20a), CMS349v3
Measure Description
Percentage of patients aged 1565 at the start of the measurement period who were between 1565 years old when tested for HIV
This is calculated as follows:
Denominator: Columns A and B
· Patients aged 15 through 65 years of age at the start of the measurement period and with at least one outpatient medical visit during the measurement period
Note: Include patients with birthdate on or after January 2, 1955, and birthdate on or before January 1, 2006.
Numerator: Column C
· Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th
birthday Exclusions/Exceptions
· Denominator Exclusions o Patients diagnosed with HIV prior to the start of the measurement period
· Denominator Exceptions o Not applicable
Specification Guidance
· This measure evaluates the proportion of patients aged 1565 at the start of the measurement period who have documentation of having received an HIV test at least once on or after their 15th birthday and before their 66th birthday.
· In order to satisfy the measure, the health center must have documentation of the administration of the laboratory test present in the patient's health record.
· HIV tests performed elsewhere must be confirmed by documentation in the chart: either a copy of the test results or correspondence between the clinic personnel and the performing lab/provider showing the results.
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· Patient attestation or self-report to meet the measure requirements is not permitted. UDS Reporting Considerations · Not applicable
Preventive Care and Screening: Screening for Depression and Follow-Up Plan (Line 21), CMS2v10
Measure Description Percentage of patients aged 12 years and older screened for depression on the date of the visit or 14 days prior to the visit using an age-appropriate standardized depression screening tool and, if screening was positive, had a follow-up plan documented on the date of the visit This is calculated as follows: Denominator: Columns A and B · Patients aged 12 years and older with at least one medical visit during the measurement period Note: Include patients with birthdate on or before January 1, 2009. Numerator: Column C · Patients who:
o were screened for depression on the date of the visit or up to 14 days prior to the date of the visit using an age-appropriate standardized tool and,
o if screened positive for depression, had a follow-up plan documented on the date of the visit. Note: Include in the numerator patients with a negative screening and those with a positive screening who had a follow-up plan documented. Exclusions/Exceptions · Denominator Exclusions
o Patients with an active diagnosis for depression or a diagnosis of bipolar disorder · Denominator Exceptions
o Patients: Who refuse to participate Who are in urgent or emergent situations17 where time is of the essence and to delay treatment would jeopardize the patient's health status Whose cognitive or functional capacity or motivation to improve may impact the accuracy of results of standardized assessment tools
17 Do not exclude patients seen for routine care in urgent care centers or emergency rooms you operate.
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Specification Guidance · The depression screening must be completed on the date of the visit or up to 14 days prior to the date of the
visit and must be reviewed and addressed in the office of the provider on the date of the visit. · If the screening result is positive, additional evaluation, assessment, referral, treatment, pharmacological
intervention, or other interventions or follow-up must be addressed in the office of the provider on the date of the visit. · Standardized depression screening tools18 are normalized and validated for the age-appropriate patient population in which they are used, must be documented in the patient health record, and must be used to meet the numerator criteria. o Examples of depression screening tools for adolescents, adults, and perinatal patients are included in the
FAQs for Table 6B. · Use the most recent screening results. · The follow-up plan must be related to a positive depression screening. · Follow-up for a positive depression screening must include one or more of the following:
o Additional evaluation or assessment for depression. o Referral to a practitioner who is qualified to diagnose and treat depression. o Pharmacological interventions. o Other interventions or follow-up for the diagnosis or treatment of depression. UDS Reporting Considerations · Although a Patient Health Questionnaire (PHQ-9)19 may follow a PHQ-2 as a new screening, if the result is positive, then a compliant follow-up plan is still required. · A suicide risk assessment does not qualify for the numerator as a follow-up plan. · Documentation of a follow-up plan "on the date of the visit" can refer to any countable visit, not only a medical visit. · DO NOT count patients who are re-screened as meeting the numerator criteria as a follow-up plan to a positive screen. · DO NOT count a PHQ-9 screening that follows a positive PHQ-2 screening during the measurement period as meeting the numerator criteria for a follow-up plan to a positive depression screening.
18 Refer to the publisher and the health center clinical team to interpret the results of screening tools. 19 A PHQ is a screening instrument used by providers to monitor the severity of depression and response to treatment.
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Depression Remission at Twelve Months (Line 21a), CMS159v9
Measure Description
Percentage of patients aged 12 years and older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event
This is calculated as follows:
Denominator: Columns A and B
· Patients aged 12 years and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9 modified for teens (PHQ-9M) score greater than 9 during the index event between November 1, 2019 through October 31, 2020 and at least one medical visit during the measurement period
Note: Include patients with birthdate on or before January 1, 2009 who were 12 years of age or older on the date of their visit.
Note: Patients may be screened using PHQ-9 and PHQ-9M up to 7 days prior to the office visit, including the day of the visit. Numerator: Column C
· Patients who achieved remission at 12 months as demonstrated by the most recent 12 month (+/- 60 days) PHQ-9 or PHQ-9M score of less than 5
Exclusions/Exceptions
· Denominator Exclusions o Patients with a diagnosis of bipolar disorder, personality disorder emotionally labile, schizophrenia, psychotic disorder, or pervasive developmental disorder o Patients: Who died Who received hospice or palliative care services Who were permanent nursing home residents
· Denominator Exceptions o Not applicable
Specification Guidance
· Not applicable UDS Reporting Considerations
· It is possible that the PHQ-9M has been mislabeled as PHQ modified for adolescents (PHQ-A). The PHQ-A is an 80+ item questionnaire (not a 9-question tool). Use a PHQ-9M version that is approved by the developers of the PHQ-9 for adolescents.
· Although PHQ-9 is not the only screening tool approved for the Screening for Depression and Follow-Up Plan measure, performance for the Depression Remission at Twelve Months must be evaluated using a PHQ-9 or PHQ-9M screening tool.
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Dental Sealants for Children between 69 Years (Line 22), CMS277v020
Measure Description Percentage of children, age 69 years, at moderate to high risk for caries who received a sealant on a first permanent molar during the measurement period Note: Although the draft eCQM reflects 5 through 9 years of age, use ages 6 through 9 as the measure steward intended. This includes patients who were 9 years of age at the beginning of the measurement period. Calculate as follows: Denominator: Columns A and B · Children 6 through 9 years of age with an oral assessment or comprehensive or periodic oral evaluation
dental visit who are at moderate to high risk for caries in the measurement period Note: Include children with birthdate on or after January 2, 2011, and birthdate on or before January 1, 2015. Numerator: Column C · Children who received a sealant on a permanent first molar tooth during the measurement period Exclusions/Exceptions · Denominator Exclusions
o Not applicable · Denominator Exceptions
o Children for whom all first permanent molars are non-sealable (i.e., molars are either decayed, filled, currently sealed, or un-erupted/missing)
Specification Guidance · The intent is to measure whether a child received a sealant on at least one of the four permanent first molars. · "Elevated risk" is a finding at the patient level, not a population-based factor such as low socioeconomic
status. · Look for tooth-level data for sealant placement. Capture sealant application within buccal pits on a first
permanent molar in the numerator. UDS Reporting Considerations · Include dental visits with the health center or with another dental provider who saw health center patients
through a referral, regardless of whether it was paid for by the health center. · Use ADA codes to document caries risk level determined through an assessment. · The electronic specifications for this measure have not been updated. Follow the CMS277v0 specifications
for UDS reporting.
20 Requires a free user login to the United States Health Information Knowledgebase (USHIK) to access measure details.
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FAQS FOR TABLE 6B
1. On which line do we count patients who began prenatal care during the first trimester? Report the patient on Line 7, depending on if they began their care with the health center or with a non-health center provider.
· If the patient began prenatal care during the first trimester at the health center's service delivery location or with a provider to which the health center referred the patient, report the patient on Line 7 in Column A.
· If the patient received prenatal care from another provider during the first trimester before coming to the health center's service delivery location, report the patient on Line 7 in Column B, regardless of when the patient begins care with the health center.
2. A child came in only once during the year for an injury and never returned for well-child care. Do we have to consider the child's chart to not have met the numerator criteria since we only treated for the injury? Yes. After a patient enters a health center's system of medical care, the center is expected to provide all needed preventive health care and/or document that the patient has received it. Report the patient in the denominator but not the numerator, since the record did not meet the numerator criteria.
3. Is the Pap test review for women starting at age 21 or at age 23? For this measure, look only at women who were age 23 through age 64 at some point in the measurement period. Because the measure asks about Pap tests administered in 2021, 2020, or in 2019, it is possible that a 23-year-old woman assessed under this measure would have been 21 in 2019. If the patient received a Pap test in that year, the patient would be considered to have met the numerator criteria. Although you look only at women who are 23 through 64, their qualifying test may have been done when they were 21 through 64.
4. What if a patient we treat for hypertension and diabetes goes to an OB/GYN in the community for reproductive health care? Do we still have to consider the patient in the denominator for the cervical cancer screening measure? What if we DO NOT offer Pap tests? After the patient has been seen in your clinic, you are responsible for ensuring that they have the appropriate cervical cancer screening. This can be done by providing the Pap test or documenting the results of a test that someone else performed. Health centers are encouraged to coordinate care and document Pap test results by contacting providers. The health center may obtain a copy of the patient's test result to include in their patient health record for future care. Consider the patient as part of the denominator for the cervical cancer screening measure if they received any medical visit(s) in the measurement period. If there is no evidence of a timely cervical cancer screening included in their patient health record, consider this as not having met the numerator criteria.
5. If we inform parents of the importance of immunizations but they refuse to have their child immunized, may we count the patient health record as having met the numerator criteria if the refusal is documented? No. A child is fully immunized only if there is documentation that the child received the vaccine or there is contraindication for the vaccine, evidence of the antigen, or history of illness. Refusal does not meet the exclusion criteria.
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6. Are parents required to bring to the health center documentation of childhood immunizations received outside the health center? Parents are encouraged to provide documentation of immunizations that their children received elsewhere, but other mechanisms of obtaining this information are also acceptable as long as all immunizations are appropriately reviewed and documented in your system. Document childhood immunizations by contacting providers of immunizations directly to obtain documentation by fax, by requesting health center patients mail a copy of their immunization history, through receipt of payment for the vaccine from the pharmacy, by finding the child in a state or county immunization registry, or through other appropriate means.
7. Some of the immunization details are different from those used by the Centers for Disease Control and Prevention (CDC) in the Clinic Assessment Software Application (CASA) or Comprehensive-CASA reviews of our clinic. May we use these CDC standards to report on the UDS? No. HRSA is now using the CMS eCQM standards to evaluate provision of vaccines to children. Using a different set of standards will distort the data. A health center may use a different set of standards for its own internal QI/quality assurance program, but these may not be substituted for the UDS reporting requirements.
8. We want to use data from the clinical quality measures to compare our service delivery sites and our providers to one another. As a result, we would like to use a larger sample size. Is this permitted? No. A sample size of 70 patient health records must be used. This facilitates the development of state, national, and other roll-up reports. Additionally, any change in the sample size would bias the sample and provide distortions in the data set. Most health center systems can provide these results without modifying the reporting requirements.
9. Does "counseling for nutrition and . . . physical activity" include specific content that must be provided? Does it need to be provided if the child is within the normal range? No, the counseling has no specific required content, although it does have specific CPT coding requirements. It is tailored by the provider given the patient's BMI percentile and other clinical and social data.
Yes, the counseling must be provided to all children and adolescents. Counseling is aimed at promoting routine physical activity and healthy eating for all children and adolescents. For younger children, counseling will be provided to the parent or caregiver.
10. For adult patients, our protocol calls for weight to be measured at every visit but height to be measured "at least once every 2 years." Is this acceptable? BMI is calculated from current height and weight. Both height and weight must be measured within 12 months of the most recent visit and may be obtained from separate visits.
11. The tobacco screening measure says that there must be intervention for tobacco users. What specific interventions must be used? A broad range of counseling and pharmacotherapy is available for tobacco use. Which intervention to use is at the discretion of each provider.
12. Do quit lines meet the numerator criteria for tobacco cessation? Yes. Tobacco cessation services provided by quit lines do meet the numerator criteria for the tobacco screening and cessation intervention measure if the intervention is documented in the patient's health record.
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13. How should we collect data for measures that require a look-back period? Many of the UDS CQMs (e.g., cervical cancer screening, colorectal cancer screening, childhood immunizations, others) require a look-back period (reference to historical data prior to the measurement period). It is important that this information is noted in patient health records. It is recommended that you obtain records for new patients from their former providers to document their prior treatment, including data for look-back periods. Patient health records obtained from other providers may be recorded in the health center's HIT/EHR consistent with internal patient health record policies, at which point they could be used in the performance review. Additionally, if you change EHRs, ensure that the prior data is transferred to the new system.
14. Can we use National Quality Forum (NQF) or Healthcare Effectiveness Data and Information Set (HEDIS) directly to report on the clinical quality measures? No. For UDS reporting, you must report on the clinical quality measures defined by UDS and outlined in this manual, most of which align with CMS's Promoting Interoperability eCQMs.
15. Which patients are we required to report in the denominator for the dental sealants measure? Health centers providing dental services directly on-site or through paid referral under contract must report on all dental patients age 6 through 9 at the start of the measurement period who are at elevated risk for caries in the denominator. Caries risk assessment must be based on patient-level factors and documented with appropriate ADA codes. This may not be based on population-based factors, such as low socioeconomic status.
16. Do DNA colorectal cancer screening tests meet the numerator criteria for the colorectal cancer screening measure? Yes. FIT-DNA colorectal cancer screening tests (such as Cologuard) meet the numerator criteria for the colorectal cancer screening measure when performed during the measurement period or in the 2 years prior.
17. What should we do if we DO NOT have adequate documentation about the tooth on which a sealant was placed? In these situations, pull 70 patient health records using a random sample and have the reviewer evaluate the patient health records to find evidence for the sealant being applied to a permanent first molar. If the tooth descriptor (or tooth number) is undocumented and there is insufficient documentation to determine whether at least one sealant was placed on a permanent first molar, the patient health record will not be included in the numerator and may lower the overall measure score (percentage).
18. If a patient who is newly diagnosed with HIV dies before they receive treatment, do we count them in the HIV linkage to care measure? Yes. Include the patient in the denominator, assuming they met the diagnosis criteria. If they died before receiving the first visit for initiation of treatment, DO NOT count them in the numerator.
19. Can brand-name prescriptions meet the numerator criteria for measures that include a pharmaceutical component? Yes. Since only scientific or generic names are stored in the RxNORM value sets, the health center and vendor need to map the generic and brand names when a new equivalent or brand name is discovered missing from RxNORM.
20. What does "diagnosis that overlaps the measurement period" mean, as stated for some of the measures? The overlap statement means that if patients had the diagnosis at any point during the measurement period, they are to be included in the denominator and assessed for meeting the numerator criteria.
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21. We would like to recommend changes to specific eCQM requirements being collected in the UDS. Can HRSA make the changes based on our feedback? Although HRSA is interested in learning about eCQM changes you would recommend, you should contact the measure steward through the ONC Issue Tracking System to submit recommendations to existing eCQM logic. Appendix G contains the list of measure stewards.
22. What standardized depression screenings comply with the Screening for Depression and Follow-Up Plan measure? Use a standardized depression screening tool, which is a normalized and validated tool developed for the patient population in which it is to be utilized. Examples of depression screening tools include, but are not limited to those listed in the following chart:
Adolescent Screening Tools (1217 years)
· Patient Health Questionnaire for Adolescents (PHQ-A)
· Beck Depression InventoryPrimary Care Version (BDI-PC)
· Mood Feeling Questionnaire (MFQ)
· Center for Epidemiologic Studies Depression Scale (CES-D)
Adult Screening Tools (18 years and older) · PHQ-9
· Beck Depression Inventory (BDI or BDI-II)
· CES-D
· Depression Scale (DEPS)
· Duke Anxiety-Depression Scale (DADS)
Perinatal Screening Tools · Edinburgh Postnatal Depression
Scale
· Postpartum Depression Screening Scale
· PHQ-9
· BDI
· BDI-II
· Patient Health Questionnaire (PHQ-9)
· Pediatric Symptom Checklist (PSC-17)
· Geriatric Depression Scale (GDS)
· Cornell Scale for Depression in Dementia (CSDD)
· CES-D
· Zung Self-Rating Depression Scale
· Primary Care Evaluation of Mental Disorders (PRIME MD)PHQ-2
· PRIME MD-PHQ-2
· Hamilton Rating Scale for Depression (HAM-D)
· Quick Inventory of Depressive Symptomatology Self-Report (QID-SR)
· Computerized Adaptive Testing Depression Inventory (CAT-DI)
· Computerized Adaptive Diagnostic Screener (CADMDD)
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TABLE 6B: QUALITY OF CARE MEASURES
Calendar Year: January 1, 2021, through December 31, 2021
0
Line 1 2 3 4 5 6
Line 7 8 9
Line 10
Line 11
Line 11a
Prenatal Care Provided by Referral Only (Check if Yes)
[blank for demonstration]
Section A--Age Categories for Prenatal Care Patients: Demographic Characteristics of Prenatal Care Patients
Age Less than 15 years Ages 1519 Ages 2024 Ages 2544 Ages 45 and over
Total Patients (Sum of Lines 15)
Number of Patients (a)
[blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration]
Section B--Early Entry into Prenatal Care
Early Entry into Prenatal Care
First Trimester Second Trimester Third Trimester
Patients Having First Visit with Health Center (a)
[blank for demonstration] [blank for demonstration] [blank for demonstration]
Patients Having First Visit with Another Provider (b)
[blank for demonstration] [blank for demonstration] [blank for demonstration]
Section C--Childhood Immunization Status
Childhood Immunization Status
MEASURE: Percentage of children 2 years of age who received ageappropriate vaccines by their 2nd birthday
Total Patients with 2nd Birthday (a)
[blank for demonstration]
Number Charts Sampled or EHR
Total (b)
[blank for demonstration]
Number of Patients Immunized (c)
[blank for demonstration]
Section D--Cervical and Breast Cancer Screening
Cervical Cancer Screening
MEASURE: Percentage of women 2364 years of age who were screened for cervical cancer
Breast Cancer Screening
MEASURE: Percentage of women 5173 years of age who had a mammogram to screen for breast cancer
Total Female Patients
Aged 23 through 64 (a)
[blank for demonstration]
Total Female Patients
Aged 51 through 73 (a)
[blank for demonstration]
Number Charts Sampled or EHR
Total (b)
[blank for demonstration]
Number Charts Sampled or EHR
Total (b)
[blank for demonstration]
Number of Patients Tested (c)
[blank for demonstration]
Number of Patients with Mammogram (c)
[blank for demonstration]
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Line 12
Line 13
Line 14a
Line 17a
Section E--Weight Assessment and Counseling for Nutrition and Physical Activity of Children and Adolescents
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents MEASURE: Percentage of patients 3 16 years of age with a BMI percentile and counseling on nutrition and physical activity documented
Total Patients Aged 3 through 16 (a)
[blank for demonstration]
Number Charts Sampled or EHR
Total (b)
[blank for demonstration]
Number of Patients with Counseling and BMI Documented (c)
[blank for demonstration]
Section F--Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
MEASURE: Percentage of patients 18 years of age and older with (1) BMI documented and (2) follow-up plan documented if BMI is outside normal parameters
Total Patients Aged 18 and Older (a)
[blank for demonstration]
Number Charts Sampled or EHR
Total (b)
[blank for demonstration]
Number of Patients with BMI Charted and
Follow-Up Plan Documented as Appropriate (c)
[blank for demonstration]
Section G--Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Total Patients Aged 18 and Older (a)
MEASURE: Percentage of patients aged 18 years of age and older who (1) were screened for tobacco use one or more times within 12 months, and (2) if identified to be a tobacco user received cessation counseling intervention
[blank for demonstration]
Number Charts Sampled or EHR
Total (b)
[blank for demonstration]
Number of Patients Assessed for Tobacco
Use and Provided Intervention if a Tobacco User (c)
[blank for demonstration]
Section H--Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
MEASURE: Percentage of patients 21 years of age and older at high risk of cardiovascular events who were prescribed or were on statin therapy
Total Patients Aged 21 and Older at High Risk of Cardiovascular Events (a)
[blank for demonstration]
Number Charts Sampled or EHR
Total (b)
[blank for demonstration]
Number of Patients Prescribed or On Statin Therapy (c)
[blank for demonstration]
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Line 18
Line 19 Line 20 Line 20a
Section I--Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
MEASURE: Percentage of patients 18 years of age and older with a diagnosis of IVD or AMI, CABG, or PCI procedure with aspirin or another antiplatelet
Total Patients Aged 18 and Older with IVD Diagnosis or AMI, CABG, or PCI
Procedure (a)
[blank for demonstration]
Number Charts Sampled or EHR
Total (b)
[blank for demonstration]
Number of Patients with Documentation of
Aspirin or Other Antiplatelet Therapy
(c)
[blank for demonstration]
Section J--Colorectal Cancer Screening
Colorectal Cancer Screening
MEASURE: Percentage of patients 50 through 74 years of age who had appropriate screening for colorectal cancer
Total Patients Aged 50 through 74 (a)
[blank for demonstration]
Number Charts Sampled or EHR
Total (b)
[blank for demonstration]
Number of Patients with Appropriate
Screening for Colorectal Cancer(c) [blank for demonstration]
Section K--HIV Measures
HIV Linkage to Care
MEASURE: Percentage of patients whose first-ever HIV diagnosis was made by health center personnel between December 1 of the prior year and November 30 of the measurement period and who were seen for followup treatment within 30 days of that first-ever diagnosis
HIV Screening
MEASURE: Percentage of patients 15 through 65 years of age who were tested for HIV when within age range
Total Patients First Diagnosed with HIV
(a)
[blank for demonstration]
Number Charts Sampled or EHR
Total (b)
[blank for demonstration]
Total Patients Aged 15 through 65 (a)
[blank for demonstration]
Number Charts Sampled or EHR
Total (b)
[blank for demonstration]
Number of Patients Seen Within 30 Days of First Diagnosis of
HIV (c)
[blank for demonstration]
Number of Patients Tested for HIV (c)
[blank for demonstration]
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Section L--Depression Measures
Number of Patients
Preventive Care and Screening: Line Screening for Depression and
Follow-Up Plan
Total Patients Aged 12 and Older (a)
Number Charts Sampled or EHR
Total (b)
Screened for Depression and Follow-Up Plan Documented as
Appropriate (c)
MEASURE: Percentage of patients 12 [blank for
[blank for
[blank for
years of age and older who were (1) demonstration]
demonstration]
demonstration]
21
screened for depression with a standardized tool and, if screening was
positive, (2) had a follow-up plan
documented
Line
Depression Remission at Twelve Months
Total Patients Aged 12 and Older with Major Depression or
Dysthymia (a)
Number Charts Sampled or EHR
Total (b)
Number of Patients who Reached Remission (c)
MEASURE: Percentage of patients 12 [blank for
[blank for
[blank for
years of age and older with major
demonstration]
demonstration]
demonstration]
21a depression or dysthymia who reached
remission 12 months (+/- 60 days)
after an index event
Section M--Dental Sealants for Children between 69 Years
Line 22
Dental Sealants for Children between 69 Years
MEASURE: Percentage of children 6 through 9 years of age at moderate to high risk of caries who received a sealant on a first permanent molar
Total Patients Aged 6 through 9 at
Moderate to High Risk for Caries (a)
[blank for demonstration]
Number Charts Sampled or EHR
Total (b)
[blank for demonstration]
Number of Patients with Sealants to First
Molars (c)
[blank for demonstration]
Note: Table 6B Cross-Table Considerations:
· Patients with medical visits on Table 5 are generally eligible for inclusion in eCQMs reported on Table 6B.
· The relationship between the denominators on Table 6B should be verified as reasonable when compared to the total number of patients by age on Table 3A and the percentage of patients by service category on Table 5.
· The count of patients by diagnosis reported on Table 6A will not be the same count as on Table 6B, due to differences in criteria that must be met for inclusion on Table 6B.
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Instructions for Table 7: Health Outcomes and Disparities
The health outcome and disparity measures reported on Table 7 are "clinical process and outcome measures," which means they document measurable outcomes of clinical intervention as a surrogate for good long-term health outcomes. Increasing the proportion of health center patients who have a good intermediate health outcome generally leads to improved health status of the patient population in the future.
The specifications for the clinical quality measures reported have been revised to align with the CMS eCQMs. The clinical quality care measures are aligned with the most current eCQMs for Eligible Professionals for the 2021 version number referenced in the UDS Manual for the measurement period. (Other updates are available, but they should not be used for the 2021 reporting.)
TABLE 7: HEALTH OUTCOMES AND DISPARITIES MEASURES
This table specifically includes the following CQMs:
Maternal Care and Children's Health · Low Birth Weight
Disease Management · Controlling High Blood Pressure
· Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)
RACE AND ETHNICITY REPORTING
Table 7 reports health outcome data by race and Hispanic or Latino/a ethnicity to provide information on health centers' efforts to reduce health disparities.
· Race and Hispanic or Latino/a ethnicity is self-reported by patients and should be collected as part of a standard registration process.
· Care must be taken by health centers that have separate reporting systems for patient registration and clinical data to ensure race and ethnicity data across the systems are aligned.
· Because the initial patient population for each measure is defined in terms of race and ethnicity, comparisons to the numbers on Tables 3B and 7 will be made when evaluating your submission. See the crosswalk of comparable fields in Appendix B.
· Health centers that report on a sample of patients are cautioned against using their data to evaluate disparities in their own systems given small sample sizes. On a national level, however, reported data permits HRSA to evaluate the impact of health center services on disparate outcomes for target populations.
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SECTION A: DELIVERIES AND BIRTH WEIGHT HIV-POSITIVE PREGNANT PATIENTS, TOP LINE (LINE 0)
· Report the total number of HIV-positive pregnant patients served by the health center during the calendar year on Line "0," regardless of whether the health center provides prenatal care or HIV treatment for these patients.
DELIVERIES PERFORMED BY HEALTH CENTER PROVIDER (LINE 2)
· Report the total number of deliveries performed by health center providers. · On this line ONLY, include deliveries, regardless of outcome, of any patient, regardless of whether or not
they were part of the health center's prenatal care program during the calendar year. Include such circumstances as: o the delivery of another doctor's patients when the health center provider participates in a call group and is
on call at the time of delivery, o emergency deliveries when the health center provider is on call for the emergency room, o deliveries of "undoctored" patients performed by a health center provider as a requirement for privileging
at a hospital, and o deliveries by any provider who is considered to be the health center's personnel during the delivery. · DO NOT include deliveries for which a clinic provider separately bills, receives, and retains payment for the delivery.
DELIVERIES AND BIRTH WEIGHT DATA BY RACE AND HISPANIC OR LATINO/A ETHNICITY, COLUMNS 1A1D
· Report on all prenatal care patients who are either provided direct care or referred for care. · Report all health center patients who delivered during the calendar year and all babies born to them in
Columns 1a1d. Include any patient of the health center who is referred to another provider for some or all of their prenatal care. · Report patients delivering (Column 1a) and babies (Columns 1b, 1c, and 1d) separately by their race and ethnicity. Obtain race and ethnicity of mothers from the information on their patient registration forms. Obtain race and ethnicity of babies from their registration forms, their birth certificates, or from their parent. · No sampling is permitted on this measure.
Prenatal Care Patients and Referred Prenatal Care Patients Who Delivered During the Year (Column 1a)
· Report all health center prenatal care patients who delivered during the calendar year, including those who health center personnel cared for and delivered and those who had some or all of their care provided by a referral provider.
· This column collects data on "patients who delivered." Report only one patient as having delivered, even if the delivery results in multiple births (e.g., twins or triplets), or is a stillbirth.
· Include all patients who had deliveries, regardless of the outcome. · DO NOT include deliveries when you have no documentation that the delivery occurred (patients lost to
inadequate follow-up).
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· DO NOT include patients who, based on their due date, should have delivered but for whom you DO NOT have explicit documentation of the delivery.
· DO NOT include miscarriages as deliveries. Note: The percentage of prenatal care patients who delivered can be calculated by dividing Table 7, Line i, Column 1a by Table 6B, Line 6, Column A. Use the cross-table guidance in Appendix B to assist with this reporting.
Birth Weight of Infants Born to Prenatal Care Patients Who Delivered During the Year (Columns 1b1d)
Low Birth Weight (Columns 1b and 1c), no eCQM Measure Description Percentage of babies of health center prenatal care patients born whose birth weight was below normal (less than 2,500 grams) Note: The reporting of this measure captures all birth weight categories, not only those birth weights that meet the numerator criteria. Calculate as follows: Denominator: Columns 1b + 1c + 1d
· Babies born during the measurement period to prenatal care patients Numerator: Columns 1b + 1c · Babies born with a birth weight below normal (under 2,500 grams) Exclusions/Exceptions · Denominator Exclusions
o Stillbirths or miscarriages · Denominator Exceptions
o Not applicable Specification Guidance · Not applicable UDS Reporting Considerations · Report the total number of live births during the calendar year for patients who received prenatal care from
the health center or a referral provider during the calendar year, according to the appropriate birth weight group (in grams): o Very Low Birth Weight (Column 1b): Weight at birth was less than 1,500 grams. o Low Birth Weight (Column 1c): Weight at birth was 1,500 grams through 2,499 grams. o Normal Birth Weight (Column 1d): Weight at birth was equal to or greater than 2,500 grams.
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Note: Be careful not to confuse pounds and ounces for grams when reporting these numbers. Include neonatal demises. · If the delivery is of multiple babies (e.g., twins or triplets), report the birth weight of each baby separately. · Report data regardless of whether the health center did the delivery or referred the delivery to another
provider, and regardless of whether the patient transferred to another provider on their own. Follow-up on all patients is required. · In rare instances, there may be no birth outcomes recorded although there may be evidence (i.e., records indicate delivery occurred) that the patient delivered. Report the patient as having delivered (Column 1a) with no birth outcomes (Columns 1b1d). · The number of deliveries reported in Column 1a will normally be different than the total number of babies reported in Columns 1b1d because of multiple births and stillbirths. · Although data are provided for each race and ethnicity category, the measure looks only at the totals.21 Note: This is a "negative" measure: The higher the number of infants born below normal birth weight, the worse the performance on the measure.
SECTIONS B AND C: OTHER HEALTH OUTCOME AND DISPARITY MEASURES
In these sections, report the findings of reviews of services provided to targeted populations. · Sections B and C specifically assess the health center's current medical patients (i.e., patients who had a
medical visit at least once during the calendar year). · Using the specified criteria, include patients seen for medical care even if the only care provided was in an
urgent care setting, if patients were seen only once for acute care, or if patients were seen only for specialty care. · DO NOT include patients whose only visits were for dental, mental health, or something other than medical care. · For measures that require the completion of tests or procedures to meet the numerator criteria, test results or procedures must be evidenced by documented results. Patient-self report is not accepted. Note: In this section, the term "measurement period" is the timeframe specified by the measure steward. For measures not electronically specified, this is intended to capture calendar year 2021 data.
21 However, during the review of the UDS Report, reviewers may question unusually high or low proportion of low-birth-weight babies for individual race or ethnicity categories.
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Controlling High Blood Pressure (Columns 2a2c), CMS165v9
Measure Description Percentage of patients 1885 years of age who had a diagnosis of hypertension overlapping the measurement period or the year prior and whose most recent blood pressure (BP) was adequately controlled (less than 140/90 mmHg) during the measurement period Calculate as follows: Denominator: Columns 2a and 2b · Patients 18 through 84 years of age who had a diagnosis of essential hypertension overlapping the
measurement period or the year prior to the measurement period with a medical visit during the measurement period Note: Include patients with birthdate on or after January 2, 1936, and birthdate on or before January 1, 2003. Numerator: Column 2c · Patients whose most recent blood pressure is adequately controlled (systolic blood pressure less than 140 mmHg and diastolic blood pressure less than 90 mmHg) during the measurement period Exclusions/Exceptions · Denominator Exclusions o Patients with evidence of ESRD, dialysis, or renal transplant before or during the measurement period o Patients with a diagnosis of pregnancy during the measurement period o Patients who were in hospice care during the measurement period o Patients aged 66 or older who were living long-term in an institution for more than 90 consecutive days
during the measurement period o Patients aged 66 and older with advanced illness and frailty · Denominator Exceptions o Not applicable Specification Guidance · Only blood pressure readings performed by a provider or remote monitoring device are acceptable for the numerator criteria with this measure. · If there are multiple blood pressure readings on the last day the patient was seen, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading. · If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled." Report them in Columns 2a and 2b, but not in Column 2c.
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· DO NOT include blood pressure readings: o taken during an acute inpatient stay or emergency department visit, o taken on the same day as a diagnostic test or therapeutic procedure that requires a change in diet or change in medication on or one day before the day of the test or procedure (with the exception of fasting blood tests), or o reported by the patient.
UDS Reporting Considerations
· Include patients who have an active diagnosis of hypertension even if their medical visits during the year were unrelated to the diagnosis.
· Include blood pressure readings taken at any visit type at the health center as long as the result is from the most recent visit.
· The remote monitoring device must capture and store the reading that is seen by the provider or care team member, and the reading must be recorded in the patient's health record at the health center.
· Although data are provided for each race and ethnicity category, the measure looks only at the totals.
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9.0 percent) (Columns 3a3f), CMS122v9
Measure Description
Percentage of patients 1875 years of age with diabetes who had hemoglobin A1c (HbA1c) greater than 9.0 percent during the measurement period
Calculate as follows:
Denominator: Columns 3a and 3b
Patients 18 through 74 years of age with diabetes with a medical visit during the measurement period
Note: Include patients with birthdate on or after January 2, 1946, and birthdate on or before January 1, 2003.
Numerator: Column 3f
· Patients whose most recent HbA1c level performed during the measurement period was greater than 9.0 percent or patients who had no HbA1c test conducted during the measurement period
Exclusions/Exceptions
· Denominator Exclusions o Patients who were in hospice care during the measurement period o Patients aged 66 or older who were living long-term in an institution for more than 90 consecutive days during the measurement period o Patients aged 66 or older with advanced illness and frailty
· Denominator Exceptions o Not applicable
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Specification Guidance
· Include patients in the numerator whose most recent HbA1c level is greater than 9.0 percent, for whom the most recent HbA1c result is missing, or for whom no HbA1c tests were performed or documented during the measurement period.
· Only include patients with an active diagnosis of Type 1 or Type 2 diabetes in the denominator of this measure.
· DO NOT include patients with a diagnosis of secondary diabetes due to another condition (such as gestational diabetes) in the denominator.
UDS Reporting Considerations
· Report patients who have an active diagnosis of diabetes even if their medical visits during the year were unrelated to the diagnosis.
· Even if the treatment of the patient's diabetes has been referred to a nonhealth center provider, the health center is expected to have the current lab test results in its records.
· Although data are provided for each race and ethnicity category, the measure looks only at the totals. Note: This is a "negative" measure: The lower the number of adult patients with diabetes with poor diabetes control, the better the performance on the measure.
FAQS FOR TABLE 7
1. When would we use Line h, "Unreported/Refused to Report" race and ethnicity? Use Line h only in those instances where patients DO NOT provide their race and DO NOT state whether they are Hispanic or Latino/a. Report patients who provide a race but DO NOT affirmatively answer a question about Hispanic or Latino/a ethnicity as Non-Hispanic or Latino/a on the appropriate race line (Lines 2a2g). Report patients who indicate they are Hispanic or Latino/a but DO NOT provide a race on Line 1g.
2. Data are requested by race and Hispanic or Latino/a ethnicity. How are these to be coded? Report race and Hispanic or Latino/a ethnicity on this table in the same manner reported on Table 3B. Refer to instructions for Table 3B for further information describing race and ethnicity categories. Ensure the same information is recorded in both the patient health record and the registration form to avoid errors.
3. Are patients with diabetes required to bring to the health center documentation of HbA1c tests received from outside the health center? The health center is required to have HbA1c test results in patient health records. If the health center does not perform the test, contact the provider who performed the tests. The documentation can be brought in by the patient, but can also be obtained by fax, by requesting that the patient mail a copy of test results, or through other appropriate means.
4. We want to use the data from the clinical quality measures to compare our service delivery sites and our providers to one another. As a result, we would like to use a larger sample size. Is this permitted? A sample size of 70 charts must be used for UDS reporting. This facilitates the development of state, national, and other roll-up reports. Additionally, any change in the sample size would bias the sample and provide distortions in the data set. Most health center systems can provide these results without modifying the reporting requirements. Health centers can use larger sample sizes for their own tracking and QI projects outside of UDS.
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UDS SUPPORT CENTER, 866-UDS-HELP, UDSHELP330@BPHCDATA.NET 5. In Section A, Deliveries and Birth Outcomes, should the race and ethnicity of the baby be the same as
that of the mother? Not necessarily. Report the race and ethnicity of the mother (Column 1a) separately from that of the baby (Column 1b, 1c, or 1d). The baby's race and ethnicity may differ from the mother's. 6. How do we report miscarriages and pregnancy terminations on this table? You don't. Report all pregnant patients in your prenatal care program (direct or by referral) on Table 6B, but report only those patients who deliver on Table 7. Consider a stillbirth to be a delivery for purposes of reporting in Column 1a, but DO NOT report the baby by birthweight in Columns 1b, 1c, or 1d. 7. How do we determine "active diagnosis" that is required for some measures? Patient health records frequently contain a "problem list," a list of "active diagnoses," or lists by other names. Any diagnosis on the list for part or all of the calendar year is considered "active." 8. Can we use our population health management system to report on the eCQMs? Possibly. Health centers that have Office of the National Coordinator for Health IT (ONC)-certified I2ITrack, personal computer dimensional measurement inspection software (PC-DMIS), a patient electronic care system (PECS), data reporting and analytics solutions (DRVS), population health management systems, or other supporting systems may use them to report the denominator only if it can be limited to the measurement period and only if it includes all required data elements (e.g., it includes data for the required time frame for all patients with hypertension from all service sites).
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TABLE 7: HEALTH OUTCOMES AND DISPARITIES
Calendar Year: January 1, 2021, through December 31, 2021
Line Description
0
HIV-Positive Pregnant Patients
2
Deliveries Performed by Health Center's Providers
Section A: Deliveries and Birth Weight
Line
<section divider cell>
1a 1b1 1b2 1c 1d 1e 1f 1g
subtotal
<blank for demonstration>
2a 2b1 2b2 2c 2d 2e 2f 2g
subtotal
<blank for demonstration>
h i
Race and Ethnicity
Hispanic or Latino/a Asian Native Hawaiian Other Pacific Islander Black/African American American Indian/Alaska Native White More than One Race Unreported/Refused to Report Race
Subtotal Hispanic or Latino/a
Non-Hispanic or Latino/a Asian Native Hawaiian Other Pacific Islander Black/African American American Indian/Alaska Native White More than One Race Unreported/Refused to Report Race
Subtotal Non-Hispanic or Latino/a Unreported/Refused to Report Race and Ethnicity Unreported/Refused to Report Race and Ethnicity
Total
Prenatal Care Patients Who Delivered During the Year
(1a)
<section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported>
<section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <section divider cell> <blank for demonstration> <cell not reported>
Patients (a) <blank for demonstration> <blank for demonstration>
Live Births: <1500 grams
(1b)
<section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported>
Live Births: 15002499 grams
(1c)
<section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported>
<section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <section divider cell> <blank for demonstration> <cell not reported>
<section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <section divider cell> <blank for demonstration> <cell not reported>
Live Births: 2500 grams
(1d)
<section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported>
<section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <section divider cell> <blank for demonstration> <cell not reported>
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Line
<blank for demonstration>
1a 1b1 1b2 1c 1d 1e 1f 1g
subtotal
<blank for demonstration>
2a 2b1 2b2 2c 2d 2e 2f 2g
subtotal
<blank for demonstration>
h
i
Section B: Controlling High Blood Pressure
Race and Ethnicity
Hispanic or Latino/a Asian Native Hawaiian Other Pacific Islander Black/African American American Indian/Alaska Native White More than One Race Unreported/Refused to Report Race
Subtotal Hispanic or Latino/a Non-Hispanic or Latino/a Asian Native Hawaiian Other Pacific Islander Black/African American American Indian/Alaska Native White More than One Race Unreported/Refused to Report Race
Subtotal Non-Hispanic or Latino/a Unreported/Refused to Report Race and Ethnicity Unreported/Refused to Report Race and Ethnicity
Total
Total Patients 18 through 84 Years of Age with Hypertension (2a)
<section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <section divider cell>
<blank for demonstration>
<blank for demonstration>
Number Charts Sampled or EHR Total (2b)
<section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <section divider cell>
<blank for demonstration>
<blank for demonstration>
Patients with Hypertension Controlled (2c)
<section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <section divider cell>
<blank for demonstration>
<blank for demonstration>
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Line
<blank for demonstration>
1a 1b1 1b2 1c 1d 1e 1f 1g
Subtotal
<blank for demonstration>
2a 2b1 2b2 2c 2d 2e 2f 2g
Subtotal
<blank for demonstration>
h
i
Race and Ethnicity
Hispanic or Latino/a Asian Native Hawaiian Other Pacific Islander Black/African American American Indian/Alaska Native White More than One Race Unreported/Refused to Report Race
Subtotal Hispanic or Latino/a Non-Hispanic or Latino/a Asian Native Hawaiian Other Pacific Islander Black/African American American Indian/Alaska Native White More than One Race Unreported/Refused to Report Race
Subtotal Non-Hispanic or Latino/a Unreported/Refused to Report Race and Ethnicity Unreported/Refused to Report Race and Ethnicity
Total
Section C: Diabetes: Hemoglobin A1c Poor Control
Total Patients 18 through 74 Years of Age with Diabetes (3a)
<section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <section divider cell>
Number Charts Sampled or EHR Total (3b)
<section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <section divider cell>
<blank for demonstration>
<blank for demonstration>
<cell not reported>
<cell not reported>
Patients with HbA1c >9.0% or No Test During Year (3f)
<section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <section divider cell> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <blank for demonstration> <cell not reported> <section divider cell>
<blank for demonstration>
<cell not reported>
Note: Table 7 Cross-Table Considerations:
· Patients with medical visits on Table 5 are generally eligible for inclusion in eCQMs reported on Table 7.
· The relationship between the denominators on Table 7 should be verified as reasonable when compared to the total number of patients by age on Table 3A, patients by race and ethnicity on Table 3B, and the proportion of medical patients on Table 5.
· The count of patients by diagnosis reported on Table 6A will not be the same counts as on Table 7, due to differences in criteria that must be met for inclusion on Table 7.
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Instructions for Table 8A: Financial Costs
Table 8A collects the total cost of all activities attributable to the calendar year that are within the approved scope of project. Total costs include all costs within the health center scope of project, regardless of source of funding (e.g., the Health Center Program award, or other grants and contracts). Thus, Table 8A describes what it costs to operate the health center's approved scope of project. There are no major changes to this table.
TABLE 8A: FINANCIAL COSTS
This table provides accrued costs and allocation of facility and non-clinical support services by cost center.
COLUMN REPORTING REQUIREMENTS
This table is made up of three columns: Accrued Costs (Column A), Allocation of Facility and Non-Clinical Support Services (Column B), and the Total Cost after Allocation (Column C). · Report the costs accrued in the calendar year, including depreciation, regardless of when (or, in the case of
donations on Line 18, if) actual cash payments were made. · Only report depreciation for capital assets, including BPHC capital grants. · Report interest payments on loans as an expense. · DO NOT report bad debts or the repayment of the principal of a loan. Note: A table summarizing the cost columns is included in FAQs for Table 8A.
Column A: Accrued Costs
· Report the accrued costs associated with each of the service delivery cost centers listed. See Line Definitions for costs to include in each category.
· Report the total facility cost and the total cost of non-clinical support services (also referred to as administrative costs) separately on Lines 14 and 15.
Column B: Allocation of Facility Costs and Non-Clinical Support Service Costs
· Report the allocation of facility and non-clinical support services costs (from Lines 14 and 15, Column A) to each of the cost centers. See Allocation Methods at the end of the instructions for this table for guidance on allocating facility and non-clinical support service costs.
Column C: Total Cost After Allocation of Facility and Non-Clinical Support Services
· Report the cost of each of the cost centers listed on Lines 113. · This cost is the sum of the direct cost, reported in Column A, plus the allocation of facility and non-clinical
support services, reported in Column B. Note: All UDS calculations involving total cost, such as total costs per patient, are based on Line 17 and DO NOT include the value of donated services, supplies, or facilities.
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COST CENTER LINE REPORTING REQUIREMENTS
· Align costs reported on Table 8A with FTEs and services reported on Table 5. A crosswalk that classifies personnel for various cost line items is available in Appendix B.
· If an individual's FTE is split across multiple lines on Table 5, the same proportional allocation must be used for that individual's personnel costs on this table.
Medical Personnel Costs (Line 1)
· Report all medical personnel costs, including salaries, fringe benefits, and training for medical care personnel reported on Table 5, Lines 112, including costs for personnel and contracted individuals.
· Include medical interns and residents who were paid directly or under a contract with their teaching institution.
· Report vouchered or contracted medical services, including the cost of any medical visit paid for directly by the health center, such as at-risk specialty care from a managed care organization (MCO) contract or other specialty care.
· Report Promoting Interoperability EHR incentive payments in the amount the health center permits the provider to retain. (Also, report Promoting Interoperability EHR incentive payments received during the calendar year from Medicare or Medicaid as cash receipts on Table 9E, Line 3a.)
· DO NOT report the costs of medical lab and X-ray personnel (report on Line 2) or dedicated HIT/EHR informatics and QI personnel (report on Line 12a).
· DO NOT report the costs of intake, patient health records, and billing and collections, as these are considered non-clinical support costs (report on Line 15).
Medical Lab and X-Ray Costs (Line 2)
· Report all costs for the provision of medical lab and X-ray services reported on Table 5, Lines 13 and 14 (including sonography, mammography, and any advanced forms of tomography), including salaries, fringe benefits, and training provided directly or under contract.
· DO NOT include other direct medical costs, including but not limited to medical supplies, equipment depreciation, and related travel (report on Line 3).
· DO NOT include dental lab and X-ray costs (report as Dental, Line 5).
· DO NOT include costs for retinography readings by specialists (most commonly for diabetic patients) (report as Vision Services, Line 9a).
Other Direct Medical Costs (Line 3)
· Report all non-personnel direct costs for medical care, including but not limited to supplies, equipment depreciation, related travel, continuing medical education (CME) registration and travel, uniform laundering, recruitment, membership in professional societies, books, and journal subscriptions.
· Report the cost of the medical aspects of an HIT/EHR system, including but not limited to the depreciation of software and hardware, training costs, and licensing fees. If the HIT/EHR system is used in other service categories (e.g., mental health, dental), allocate costs to each of the services in which it is used.
· DO NOT report non-clinical support services and facility costs associated with these cost centers (report on Lines 14 and 15, Column A, and then allocate them to the cost center in Column B). (See also FAQs for Table 5).
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Total Medical (Line 4)
Sum Lines 1 + 2 + 3.
Other Clinical Services (Lines 510)
This category includes personnel and related costs for dental, mental health, substance use disorder, pharmacy, vision, and services rendered by other professional personnel (e.g., chiropractors, naturopaths, occupational and physical therapists, speech and hearing therapists, podiatrists). Unlike medical, all costs are included on a single line.
· Report all direct costs for the provision of services in the listed service area, including but not limited to personnel, fringe benefits, training, contracted services, office supplies, equipment depreciation, related travel, HIT/EHR, lab services, and X-ray.
· DO NOT report non-clinical support services and facility costs associated with these cost centers (report on Lines 14 and 15, Column A, and then allocate them to the cost center in Column B). (See also FAQs for Table 5).
Dental (Line 5)
· Report all direct costs for the provision of dental services reported on Table 5, Lines 1618.
Mental Health (Line 6)
· Report all direct costs for the provision of mental health services reported on Table 5, Lines 20a20c, other than substance use disorder services.
· If a behavioral health program provides both mental health and substance use disorder services, the cost should be allocated between the two services. Allocations must align with FTEs and visits reported on Table 5.
Substance Use Disorders (Line 7)
· Report all direct costs for the provision of substance use disorder services reported on Table 5, Line 20. · If a behavioral health program provides both mental health and substance use disorder services, the cost
should be allocated between the two services. Allocations must align with FTEs and visits reported on Table 5.
Pharmacy (Not Including Pharmaceuticals) (Line 8a)
· Report all direct costs for the provision of pharmacy services reported on Table 5, Line 23. · If 340B drugs are purchased by or on behalf of a clinic and dispensed by a contract pharmacy, report the full
dispensing fee and any other service fees (such as "share of profit," pharmacy benefit manager costs, inventory fees, ordering fees, administrative fees, or a charge for pharmacy computer services) on this line, regardless of whether the health center pays the full amount, pays a net after subtraction of revenue at the contract pharmacy, or simply receives a reduced net payment from the pharmacy. · DO NOT include the cost of pharmaceuticals (report on Line 8b). · DO NOT report the cost of personnel engaged in assisting patients to become eligible for free pharmaceuticals from manufacturers (often called PAPs) (report as Eligibility Assistance on Line 11e).
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Pharmaceuticals (Line 8b)
· Report all costs for the purchase of pharmaceuticals only. · Include vaccines and medications administered at the health center (e.g., penicillin, Depo-Provera,
buprenorphine). · Report the full cost of 340B drugs purchased by or on behalf of the clinic and dispensed by a contract
pharmacy. This includes 340B drugs paid for in full by the health center, net payment after subtraction of revenue at the contract pharmacy, or receipt of a reduced net payment from the pharmacy. · DO NOT include other supplies here (report on Line 8a, Pharmacy). · DO NOT include the value of donated pharmaceuticals (report on Line 18, Column C).
Other Professional (Line 9)
· Report all direct costs for the provision of other professional and ancillary health care services reported on Table 5, Line 22, including but not limited to podiatry, chiropractic, acupuncture, naturopathy, speech and hearing pathology, or occupational and physical therapy. (A more complete list appears in Appendix A.)
Note: Use the "specify" field to detail the other professional costs reported on this line.
Vision (Line 9a)
· Report all direct costs for the provision of vision services reported on Table 5, Lines 22a22c, including optometry, ophthalmology, and vision support personnel.
· Include frames and lenses. · Include costs for retinography (e.g., for diabetic patients) and any contracted costs with reading the results.
Total Other Clinical (Line 10)
Sum of Lines 5 + 6 + 7 + 8a + 8b + 9a.
Enabling (Lines 11a11h, 11)
Enabling services include a wide range of services that support and assist primary care and facilitate patient access to care. Report all direct costs for the provision of enabling services reported on Table 5, Lines 2428, including salary, fringe benefits, supplies, equipment depreciation, related travel, and contracted services.
· Report enabling services by function. Use Lines 11a11h to detail the cost of seven specific types of enabling services and an "other" category for all other forms of enabling services. o Case management (11a) o Transportation (11b) o Outreach (11c) o Patient and community education (11d) o Eligibility assistance (includes assistance in obtaining program eligibility, including PAP and health insurance coverage options) (11e)
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o Translation/interpretation services (11f) o Other (specify the other forms of enabling services included on this line if used) (11g) o Community health workers (11h) · Be sure costs are allocated in each of these enabling categories consistent with the personnel and (for Lines 11a and 11d) visits reported on Table 5. If they are not (perhaps because the expenses are for non-personnel items or because of donated services, personnel, or supplies), provide an explanation. Note: Descriptions of the services and personnel that belong in each of these categories are included in the Instructions for Table 5 and in Appendix A.
Total Enabling Services (Line 11)
Sum of Lines 11a + 11b + 11c + 11d + 11e + 11f + 11g + 11h.
Other Program-Related (Line 12)
· Report all direct costs of programs that, although within the health center scope of project, are not directly a part of the listed medical, dental, behavioral, or other health services listed and reported on Table 5, Line 29a.
· Include programs and items such as WIC, child care centers, ADHC centers, fitness centers, Head Start and Early Head Start, housing, clinical trials, research, employment training, the cost of space leased to others, retail pharmacy services provided to non-health-center patients, the amount of grant funds passed through to other agencies (if not already including in other cost center categories on this table), and similar activities.
· Report salaries, fringe benefits, supplies, equipment depreciation, related travel, and contracted services. · Report the estimated cost of facilities, programs, or services that may be part of the health center scope of
project but are not tied to health center patient activity. Examples might include renting out space in the health center or providing retail pharmacy services to non-patient members of the community. · Describe the program costs using the "specify" field provided.
Quality Improvement (QI) (Line 12a)
· Report all direct costs for the health center's QI program reported on Table 5, Line 29b, including all personnel who are dedicated in whole or in part to QI.
· Include costs of personnel dedicated to the QI program and/or HIT/EHR system development and analysis, their fringe benefits, supplies, equipment depreciation, related travel, and contracted services.
· DO NOT allocate portions of costs and time that QI personnel spend attending meetings, participating in peer review, designing or interpreting QI findings, and so on to other service categories.
Total Enabling, Other Program-Related, and Quality Improvement Services (Line 13)
Sum of Lines 11 + 12 +12a.
Facility Costs (Line 14)
· Report facility costs reported on Table 5, Line 31, including all personnel dedicated to facility services, their fringe benefits, supplies, equipment depreciation, related travel, and contracted services.
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· Include rent and/or depreciation (not gross cost), facility mortgage interest (but not principal) payments, utilities, security, grounds keeping, facility maintenance and repairs, janitorial services, and all other related costs.
· DO NOT report space leased to others on this line. Instead, report it as Other Program-Related costs on Line 12.
Non-Clinical Support Services Costs (Line 15)
· Report non-clinical support services costs (sometimes referred to as administrative costs) reported on Table 5, Lines 30a30c and 32, including the cost of all non-clinical support services personnel, senior administrative personnel (CEO, CFO, COO, HR director, et al.), billing and collections personnel, patient health records and intake personnel, and the costs associated with them.
· Include salaries, fringe benefits, supplies, equipment depreciation, related travel, and contracted services. · Report corporate costs (e.g., purchase of facility and liability insurance not including malpractice insurance,
audits, legal fees, interest payments on non-facility loans, and communication costs including phone and internet). · Report costs attributable to the board of directors, including travel, expenses, meetings, directors' and officers' insurance, registration and attendance at state or national meetings, and so forth. · Some grant programs limit the proportion of grant funds that may be used for non-clinical support services. DO NOT consider those limits on "administrative" costs for those programs when completing Lines 14 and 15. The non-clinical support services and facility categories for this report include all such personnel working at the health center, whether or not that cost was identified as "administrative" in any other grant application.
· DO NOT report bad debt expenses here or report them anywhere on this table. Report self-pay bad debt as an
adjustment to patient self-pay charges on Table 9D, Line 13.
Total Facility and Non-Clinical Support Services (Line 16)
Sum of Lines 14 + 15.
Total Accrued Cost (Line 17)22
Sum of Lines 4 + 10 + 13 + 16.
Value of Donated Facilities, Services, and Supplies (Line 18, Column C)
· Report the total imputed (assigned) value of all in-kind and donated services, facilities, and supplies that are necessary to the health center's operation applicable to the calendar year and within your scope of project as follows.
· Report the estimated reasonable acquisition cost of donated personnel, supplies, services, space rental, and depreciation for the use of donated equipment.
· Report donated pharmaceuticals (including vaccines) at the price that would be paid under the federal Section 340B Drug Pricing Program, not the manufacturer's suggested retail price.
· Estimate reasonable acquisition cost of donated personnel at the cost of hiring comparable personnel.
22 This is the amount used in any BPHC calculation that is based on total cost.
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· If the health center is not paying NHSC for assignees, include the full market value of NHSC federal assignee(s), including "ready responders." Capitalize NHSC-furnished equipment, including a dental operatory, at the amount reported on the NHSC Equipment Inventory Document, and report the appropriate depreciation expense for the calendar year.
· Use the "specify" field provided to describe the donated items and amounts in detail. · DO NOT include the value of donations in Column A on the lines above.
· DO NOT use the sum of the usual and customary charges rendered by providers who donate their services to
value their donation.
Total with Donations (Line 19)
Sum of Lines 17 + 18, Column C.
FACILITY AND NON-CLINICAL SUPPORT SERVICES ALLOCATION INSTRUCTIONS
There are multiple ways that facility and non-clinical support services (Lines 14 and 15, Column A) may be allocated to the cost centers in Column B (Lines 113).
· Use the simplest method that produces a reasonably accurate result that is comparable to that obtained by a more complex method.
· Use the method described below if a more accurate method is not available. · It is recommended that allocations of facility and non-clinical support costs to a cost center be done when
they are a significant portion of the cost being allocated to the cost center. For instance, the facility and nonclinical support costs of a service delivery site that only provides dental services can be directly associated with Dental, Line 5. The EHR support personnel who support the medical department can be directly allocated to Medical, Line 1. · The remaining allocation of indirect costs can be done using a single or multi-step allocation process such as those described below. · A simple one-step method is to use the proportion each cost center's direct cost is of total cost (minus facility, non-clinical support, and pharmaceuticals). The resulting percentage is multiplied by the total Facility and Non-Clinical Support Services cost (Line 16) to arrive at the overhead allocation for that cost center.
Facility
The indirect facility cost is commonly allocated based upon the proportion of square feet used by each cost center at each location.
Note: The record of square feet used by each cost center at each location should be updated each year.
Non-Clinical Support Services
Some of the indirect non-clinical support costs may be allocated separately based on known use or other factors.
· Adjust for decentralized front desk personnel, billing and collection systems and personnel, etc. · Allocate costs for billing and accounting systems based on use. · Allocate various components of non-clinical services based on their use when these amounts are significant
and the use is not shared equally.
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· Allocate a lesser percentage to large purchased service costs that are known to consume less overhead.
· Allocate the remaining indirect non-clinical support cost to each cost center based on the proportion each cost center's direct cost plus previously allocated overhead cost is of the total of those costs.
Other Allocation Considerations
· Lines 1 and 3 both refer to aspects of the medical practice. It is acceptable to report the allocation of all medical facility and non-clinical support services on Line 1 if a more appropriate allocation between Lines 1 and 3 is not available.
· Pharmaceuticals (Line 8b) does not have an open cell to report an allocation. This is because pharmaceuticals are a purchased service that consumes a significantly lesser facility and non-clinical support charge than services involving personnel. Any allocation of overhead (which is usually minimal) that you choose to make for pharmaceuticals must be reported on Line 8a.
· There may be sizable contracted or purchased services that use less facility and non-clinical support. A lesser allocation may be appropriate.
FAQS FOR TABLE 8A
1. How do we account for donated services? If a provider comes to your health center and renders a service to your patients, report both the FTE (on Table 5) and the value, which is determined by "what an individual would reasonably pay" for the time (not the service), on Table 8A, Line 18. For example, if an optometrist sees five patients in a 2-hour period, report the amount you would pay an optometrist for 2 hours of work, not the total charges for the five visits.
However, if you refer a patient to a provider outside of your health center for a service and the provider donates these services, DO NOT report the activity, the charge, or the value of the time or service on the UDS. This is outside of the health center's scope of project and is considered a donation made by the external provider to the patient. For example, if you refer a patient to a cardiologist who provides free consultation, DO NOT count the visit or the monetary value of the provider's service.
2. How do we account for donated drugs? If drugs are donated directly to the health center, which then dispenses them to a patient, calculate and report on Line 18 the value of the drug at what a reasonable payer would pay for them. This is NOT the retail cost of the drug; it is the 340B price of the drug--an amount that is generally 4060 percent of the average wholesale price (AWP). Drugs donated directly to the patient are not health center donations and are not reported on the UDS.
3. We get most of our vaccines through Vaccines for Children (VFC) or other state and county programs. Are these considered donated drugs and accounted for here? Yes. Report the value of donated drugs that are used in the health center, such as vaccines, on Line 18 in Table 8Aagain, at the reasonable cost based on 340B drug pricing or a discounted price off the AWP.
4. Our doctors were paid the EHR incentive payments directly by CMS. If we let them keep some or all of these dollars, are they reported anywhere on Table 8A? Yes. Establish reporting mechanisms whereby your providers inform you of payments received and account for these funds. If providers are permitted to retain some or all of these funds, report the amount on Line 1. In addition, report the Promoting Interoperability EHR payments received from Medicare or Medicaid on Table 9E, Line 3a.
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5. What method of overhead (facility and non-clinical support services) allocation should we use for this table? There are multiple ways that facility and non-clinical support services may be allocated to the cost centers in Column B. Use the simplest method that produces a reasonably accurate result that is comparable to that obtained by a more complex method. See the suggested single and multi-step allocation methods for additional information on these methods.
6. Do we need to allocate overhead for contracted services? Contracted services DO NOT warrant a full overhead charge, given that they DO NOT involve the management of personnel. However, the procurement and supervision of those arrangements do consume overhead that should be reported. Contracted services are often charged at a rate that covers the cost of accounting and contract management.
7. Why do our financial statements not tie to the UDS financials? The UDS financials (Tables 8A, 9D, and 9E) will not tie to your financial statements for the following possible reasons:
(1) The UDS is reported on a calendar year basis, January 1December 31, but the health center's fiscal year may be a different period.
(2) Activity outside the scope of the federal project is included in the health center's financial statements but excluded in the UDS.
(3) Net patient service revenue that could be estimated from table 9D (charges less adjustments) may differ from the financial statements because the UDS only reports self-pay bad debt rather than the full adjustment for bad debt attributable to all payers and circumstances.
(4) Settlement and wrap revenue is only reported in the UDS upon its receipt, and health centers may be able to recognize some or all of the revenue on an accrual basis in the period it is earned.
(5) Table 9E reports all non-patient service-related revenue on a cash basis, and health centers will recognize this revenue on an accrual basis in their financial statements.
8. What do we need to report in the different columns of this table? The column definitions are detailed on Table 8A. Below is a summary of what to include in each column.
Accrued Cost (a)
Costs attributable to the calendar year by cost center. Report costs of: · personnel · fringe benefits · supplies · equipment · depreciation · interest paid · related travel Exclude bad debt and repayment of principal on loans.
Allocation of Facility and NonClinical Support Services (b)
Allocation of facility and nonclinical support services (Column A, Lines 14 and 15) to each cost center.
Note: Total of Column B must be equal to Column A, Line 16.
Total Cost After Allocation of Facility and Non-Clinical Support
Services (c) Represents cost to operate services.
Note: Sum of Columns A + B (done automatically in EHBs).
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UDS SUPPORT CENTER, 866-UDS-HELP, UDSHELP330@BPHCDATA.NET 9. How are awardee-subrecipient and contractor relationships to be reported?
Report the full scope of subawardee project operations in the UDS Report of the awarded health center that provided a subaward to the other health center (subawardee). If the subawardee is also a Health Center Program awardee, the subawardee will also report the subaward activity on its UDS. Activity associated with contracts for services purchased by one health center and provided by another health center will be reported in the UDS Report of both health centers. The health center providing the services reports the activity of the services provided. The health center purchasing the services reports the activity of the services purchased. 10. How do we report the cost of shared or common space? All facility costs, including for common space, are reported on Line 14, Facility, in Column A, Accrued Costs. When allocating the space of a building (in Column B), allocate the shared space used by multiple cost centers, such as hallways, waiting rooms, and equipment rooms, using a method that will distribute that portion of indirect costs to the multiple cost centers that share the space (e.g., distribute with non-clinical support costs to the service category).
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TABLE 8A: FINANCIAL COSTS
Calendar Year: January 1, 2021, through December 31, 2021
Line Cost Center
Accrued Cost (a)
[section divide]
1 2 3 4
[blank for section divide]
5 6 7 8a 8b 9
9a 10
[blank for section divide]
11a 11b 11c 11d 11e 11f 11g
11h 11
12
12a 13
Financial Costs of Medical Care
Medical Personnel Lab and X-ray Medical/Other Direct
Total Medical Care Services (Sum of Lines 1 through 3)
Financial Costs of Other Clinical Services Dental Mental Health Substance Use Disorder Pharmacy (not including pharmaceuticals) Pharmaceuticals Other Professional (specify___) Vision
Total Other Clinical Services (Sum of Lines 5 through 9a)
Financial Costs of Enabling and Other Services Case Management Transportation Outreach Patient and Community Education Eligibility Assistance Interpretation Services Other Enabling Services (specify___) Community Health Workers
Total Enabling Services (Sum of Lines 11a through 11h) Other Program-Related Services (specify___)
Quality Improvement Total Enabling and Other Services (Sum of Lines 11, 12, and 12a)
[section divide]
[blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration]
[blank for section divide]
[blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration]
[blank for demonstration] [blank for demonstration]
[blank for section divide]
[blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration]
[blank for demonstration] [blank for demonstration]
[blank for demonstration]
[blank for demonstration] [blank for demonstration]
Allocation of Facility and NonClinical Support
Services (b)
[section divide]
[blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration]
[blank for section divide]
[blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [Cell not reported] [blank for demonstration]
[blank for demonstration] [blank for demonstration]
[blank for section divide]
[Cell not reported] [Cell not reported] [Cell not reported] [Cell not reported] [Cell not reported] [Cell not reported] [Cell not reported]
[Cell not reported] [blank for demonstration]
[blank for demonstration]
[blank for demonstration] [blank for demonstration]
Total Cost After Allocation of
Facility and NonClinical Support
Services (c)
[section divide]
[blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration]
[blank for section divide]
[blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration]
[blank for demonstration] [blank for demonstration]
[blank for section divide]
[blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration]
[blank for demonstration] [blank for demonstration]
[blank for demonstration]
[blank for demonstration] [blank for demonstration]
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Line Cost Center
Accrued Cost (a)
[blank for section divide]
Facility and Non-Clinical Support
[blank for section divide]
Services and Totals
14 Facility
[blank for demonstration]
15 Non-Clinical Support Services
[blank for demonstration]
16
Total Facility and Non-Clinical Support [blank for demonstration]
Services
(Sum of Lines 14 and 15)
17
Total Accrued Costs [blank for demonstration]
(Sum of Lines 4 + 10 + 13 + 16)
18
Value of Donated Facilities, Services, and [Cell not reported]
Supplies (specify___)
19
Total with Donations [Cell not reported]
(Sum of Lines 17 and 18)
Allocation of Facility and NonClinical Support
Services (b)
[blank for section divide]
[Cell not reported] [Cell not reported] [Cell not reported]
[Cell not reported]
[Cell not reported]
[Cell not reported]
Total Cost After Allocation of
Facility and NonClinical Support
Services (c)
[blank for section divide]
[Cell not reported] [Cell not reported] [Cell not reported]
[blank for demonstration]
[blank for demonstration]
[blank for demonstration]
Note: Table 8A Cross-Table Considerations:
· The personnel and visits on Table 5 are routinely compared to the costs on Table 8A. See the crosswalk of comparable fields in Appendix B.
· Report only non-monetary donations and in-kind services on Table 8A. Report cash donations on Table 9E.
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Instructions for Table 9D: Patient Service Revenue
This table collects patient service revenue, including charges, collections, and adjustments attributable to the calendar year.
The statute requires that all health centers have a fee schedule, based on locally prevailing rates and actual health center costs, and that they discount these fees (see discussion regarding sliding fee discounts), based on a patient's income and family size. Health centers are also required to make reasonable efforts to collect payment from patients and/or their third-party payers, consistent with Health Center Program Compliance Manual requirements.
There are no major changes to this table.
TABLE 9D: PATIENT SERVICE REVENUE
This table provides information about the health center's payments for billed charges of in-scope activities.
Revenue reported on Table 9D generally aligns with patient insurance enrollment reported on Table 4. A crosswalk that shows this alignment is available in Appendix B.
ROWS: PAYER CATEGORIES AND FORM OF PAYMENT
Five major payer categories are listed: Medicaid, Medicare, Other Public, Private, and Self-Pay. Medicaid, Medicare, and Private all have three sub-categories: non-managed care, capitated managed care, and fee-forservice managed care.
Only report as managed care if the health center has a contract with an MCO.
Form of Payment
Non-Managed Care--Fee-for-Service
A payment model in which procedures and services are separately charged and paid. Third-party payers pay some or all of the bill, generally based on agreed-upon maximums or discounts.
Managed Care--Capitated
A payment model in which a health center contracts with an MCO for a list of services covered under contract. The MCO pays the health center a capitation fee (a set, usually monthly amount for each patient enrolled with the health center) regardless of whether any services were rendered during the month. No further payment is provided if the services rendered are on a list of services covered by the capitation in the agreement between the health center and the MCO.
Note: A supplemental wraparound payment may be made for each visit to adjust total payment to equal federally qualified health center (FQHC) cost-based rates.
Managed Care--Fee-for-Service
A payment model in which a health center contracts with an MCO, is assigned patients who must receive their primary care from the health center, and is reimbursed on a fee-for-service (or encounter-rate) basis for covered services.
Note: A supplemental wraparound payment may also be paid for Medicaid and Medicare services.
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Payer Categories
Medicaid (Lines 13)
· Report all services billed to and paid for by Medicaid (Title XIX), including: o Medicaid managed care programs run by private insurers. For example, in states with a capitated Medicaid program, where the health center has a contract with a private plan like Blue Cross to administer the plan, the payer would be Medicaid, even though the actual payment may have come from Blue Cross. o EPSDT, which has various names in different states and is a part of Title XIX. The EPSDT program includes some children who are eligible for the screening services only and are not included in the rest of the Medicaid program. Report their charges on Line 1. o CHIP, which has different names in different states, if paid through Medicaid. o Medicaid expansion programs that provide funds for eligible individuals to purchase their own insurance, if it is possible to identify them. Otherwise report as Private. o The portion of charges for dually eligible patients that are reclassified to Medicaid after being initially submitted to Medicare. o The portion of the fee paid by Medicaid for Medicaid patients enrolled in a "share of cost" program. o ADHC or Program of All-Inclusive Care for the Elderly (PACE) if administered by Medicaid. Treat as discussed in Appendix B.
Medicare (Lines 46)
· Report all services billed to and paid for by Medicare (Title XVIII), including: o Medicare managed care programs, including Medicare Advantage run by private insurers. For example, where the health center has a contract with a private plan like Blue Cross for Medicare Advantage, consider the payer to be Medicare, even though the actual payment may come from Blue Cross. o The portion of charges for patients covered through multiple insurances (e.g., Medicare and Medicaid, Medicare and Private) that are initially paid for by Medicare. o ADHC or PACE if administered by Medicare. Treat as discussed in Appendix B.
Other Public (Lines 79)
· Report all services billed to and paid for by state or local government programs, including: o CHIP when paid for through private insurers. (See Lines 13 if CHIP is paid through Medicaid.) o Family planning programs such as Title X programs, BCCCPs (with various state names), and other dedicated state or local programs. Note: Although these programs are considered Other Public payers, patients are generally classified as Uninsured on Table 4. o State-run insurance plans. o Municipal or county jails and state prisons. o Public educational schools and institutions that engage with the health center on a fee-for-service or other service-based contract basis.
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o Testing and treatment associated with caring for uninsured patients with suspected or actual COVID-19 administered by HRSA under the COVID-19 Uninsured Program on Line 8c.
· DO NOT include: o State or local indigent care programs. Report their charges, any associated self-pay collections, etc. on the Self-Pay line of Table 9D, Line 13, as described below. o Third-party coverage purchased through state or federal exchanges (which may be subsidized). Report as Private. o Patients covered through subsidies from a Medicaid expansion program. Report as Medicaid.
Private (Lines 1012)
· Report all services billed to and paid for by private (commercial) insurance companies or by other third-party payers, including: o Insurance purchased for public employees or retirees, such as Tricare, Trigon, and the Federal Employees Insurance Program, as well as workers' compensation, as these are benefits belonging to the patient. o Insurance purchased through state exchanges, unless you can identify the patient as being enrolled through purchased subsidies from a Medicaid expansion program. o Contract payments from other organizations who engage the clinic on a fee-for-service or other reimbursement basis, such as a Head Start program that pays for annual physical exams at a contracted rate or a private school, private jail, or large company that pays for a provision of medical care at a persession or other negotiated rate. o Supplemental insurance (typically covers some amounts not paid or disallowed by Medicare).
· DO NOT report Medicaid, Medicare, or Other Public managed care programs administered by private insurers.
Self-Pay (Line 13)
· Report all charges and collections where the patient is responsible, including: o Co-payments, deductibles, and charges to insured individuals for uncovered services that become the patient's personal responsibility. o Medicaid patients enrolled in a "share of cost" program in which they pay some portion of the fee as a copayment or a deductible. In this case, reclassify the patient's share of the cost to Self-Pay, Line 13. o State or local indigent care programs that subsidize services rendered to the uninsured. Report all charges for these services and collections from patients on the Self-Pay line (Line 13, Columns A and B). Report all amounts not collected or due from the patients as sliding fee discounts or bad debt write-off, as appropriate, on Line 13, Columns E and F. Report collections from the associated state and local indigent care programs on Table 9E, Line 6a, and specify the name of the program paying for the services.
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COLUMNS: CHARGES, PAYMENTS, AND ADJUSTMENTS RELATED TO SERVICES DELIVERED
Column A: Full Charges This Period
· Report total charges for each payer source. This will initially reflect the total full charges (per the health center's fee schedule) for services rendered to patients in that payer category during the calendar year.
· Report charges based on the organization's fee schedule for services that are billed to and covered in whole or in part by a payer, or the patient, even if some or all of them are subsequently written off as contractual adjustments, sliding fee discounts, or bad debts. Always report full gross charges according to the health center fee schedule, not a contracted or negotiated rate.
Note: Under no circumstances should the actual amount paid by Medicaid or Medicare (such as FQHC, G code, or T code rates) or the amount paid by any other payer be used as the actual charges. Charges must come from the health center's schedule of fees, typically based on CPT codes, or retail charge (for pharmacy).
· Report pharmaceuticals dispensed through a (340B) contract pharmacy at the pharmacy's UCR gross charge, even though they are sold at a discount to clinic patients.
· Include charges for eyeglasses, pharmaceuticals, durable medical equipment, and other similar supply items. · Include charges for dispensing or injecting donated pharmaceuticals to the health center or directly to a
patient through the health center if they appear on bills and are collected from first and third parties. · Report charges for services that are "carved out" of managed care capitation contracts (i.e., not included in the
listed services under contract) as managed care fee-for-service. DO NOT report: · "contractual adjustments" as a charge. Instead, report the difference between gross charges and contracted
payments from third parties as described in Adjustments. · charges that are generally not billable to or covered by traditional third-party payers. Some examples include
WIC services, parking or job training, and transportation and similar enabling services (not generally included in Column A, except where the payer [e.g., Medicaid] accepts billing and pays for these services). Reclassifying Charges
Some patients have more than one source of payment for their services. Management information systems should automatically reclassify charges rejected by a payer.
· In these instances, report the charge accepted by the primary payer along with any negotiated adjustment amount for their portion of the services to that payer line.
· Move the charges for the balance to the secondary payer; after the secondary payer claim settles, move the balance to a tertiary payer (if one exists) and, eventually, to the patient as a self-pay charge.
· Only report the amount owed by each payer after reclassifying charges to the appropriate payer. · If reclassifying cannot be done automatically, manually remove the amount rejected from the initial payer
before reclassifying to the next payer. · DO NOT reclassify charges by using an adjustment and rebilling to another payer category; this will result in
an overstatement of total gross charges by reporting the charges twice.
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Column B: Amount Collected This Period
· Report in Column B the gross receipts for the calendar year, regardless of the period in which the paid services were rendered.
· Report FQHC reconciliations, managed care pool distributions, pay-for-performance (P4P) payments, quality bonuses, court settlements, and other payments in Column B and in Columns c1, c2, c3, and/or c4.
· When a contract pharmacy is dispensing 340B drugs on behalf of the health center, report the total cash received by the pharmacy from patients and third parties.
· Report the managed care capitation (monthly payment) received during the calendar year as a collection, not as an additional charge, on the capitation line.
Note: Report charges and collections for deductibles and co-payments that are charged to, paid by, and/or due from patients as Self-Pay on Line 13.
Columns C1C4: Retroactive Settlements, Receipts, or Paybacks
· Report in Columns c1c4 retroactive settlements, receipts, and paybacks, in addition to including them in Column B. The most common are Medicaid, Medicare, and CHIP FQHC prospective payment system (PPS) reconciliations and wraparound payments. Reconciliations are lump sum retroactive adjustments based on the filing of a cost report. Wraparound payments are additional amounts for each visit to bring payment up to FQHC level.
· Include managed care pool distributions, P4P payments, quality bonuses, and paybacks to FQHC payers or HMOs.
· Report retroactive payments received from third parties from either a current or prior calendar year in Column B, subtract from Column D, and also report in Columns c1c3.
· DO NOT report wraparound payments if the State pays the FQHC rate upon billing. States that pay the FQHC rate rather than a market rate will typically not make wraparound reconciliation payments.
Column C1: Collection of Reconciliation/Wraparound, Current Year
· Report FQHC cash receipts from reconciliations and wraparound payments from Medicare, Medicaid, or Other Public payers that are for services provided during the current calendar year. Include the currentyear component, if any, of multi-year settlements here.
Column C2: Collection of Reconciliation/Wraparound, Previous Years
· Report FQHC cash receipts from reconciliations and wraparound payments from Medicare, Medicaid, or Other Public payers that are for services provided during previous calendar years. Include the prior-year component of multiyear settlements here.
Note: Apportion settlement data reported in Columns c1 and c2 between the fee-for-service lines and the managed care lines when both payment reimbursement methods are used. You may use the percent distribution of visits, charges, or net charges as the basis for the allocation if exact amounts are unknown.
Column C3: Collection of Other Payments Including Pay for Performance, Quality Bonuses, Risk Pools, and Incentives
· Report other cash payments, including managed care risk pool redistribution, incentives including P4P incentives, and quality bonuses from any payer.
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· Include payment for patients enrolled in the CMS primary care demonstration grant, regardless of whether there is a visit involved.
· Report settlements that result from a court decision that requires a payer to make a settlement, including a multiyear settlement. These payments may apply to either a managed care or non-managed care payer.
· DO NOT report eligible provider payments from CMS for implementing EHRs (commonly referred to as
Promoting Interoperability payments). Report these payments on Table 9E, Line 3a.
Column C4: Penalty/Payback
· Report payments made by the health center to payers because of overpayments collected earlier. Only report amounts paid back during the calendar year.
· Report "penalty" payments made to managed care plans for overutilization of the inpatient or specialty pool funds.
· If a check was written for the payback, report the payback amount in Column c4, subtract this amount from Column B, and add it to Column D as an adjustment.
· If the payback amount is deducted from a remittance, report it in Column c4, but DO NOT adjust Columns B or D.
· DO NOT include as paybacks anticipated bonuses or payouts that were not earned because P4P goals were not met, regardless of whether they were budgeted.
Column D: Adjustments
Virtually all insurance companies have a maximum amount they pay for a given service and the health center agrees to write off the difference between what they charge and that contracted amount. These are considered contractual adjustments.
· Report in Column D adjustments granted as part of an agreement with a third-party payer.
· Report adjustments as a positive number, unless as you reduce the initial adjustment by the amount of retroactive settlements and receipts (reported in Columns c1, c2, and c3), current- and prior-year FQHC reconciliations, managed care pool distributions, quality or P4P awards, and other payments the result is a negative number.
Note: Adjustments that have the normal effect of reducing the charge are reported without brackets or a minus sign in Column D, and those that have the effect of increasing charges are reported as a negative number.
· Capitated managed care plans only (Lines 2a, 5a, 8a, and 11a only) typically pay on a per-member, per-month basis and make payments in the current month of enrollment, which means these plans DO NOT carry significant receivables. In these instances, report the difference between the charges for the capitated services provided and the capitation earned during the calendar year (Column A minus Column B) as the adjustment (Column D), unless there are early or late capitation payments.
· No adjustments can be entered on Line 13 (self-pay), because patient adjustments are recognized as either sliding fee discounts (Line 13, Column E) or as self-pay bad debt (Line 13, Column F).
· If your organization records capitation receipts in the general ledger, this will require that the charges for capitation services be eliminated from the PMS with an adjustment, as no payment is expected to be recorded in the PMS. DO NOT report these in Column D. Only report adjustments in Column D that are the difference between the charges for capitated services and the capitations earned. If the capitations earned were all received during the calendar year, the adjustment will equal the difference between Column A and Column B.
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If not all of the capitations earned were received during the calendar year, Column A less Column B less Column D will equal the capitation amount due to the health center. · DO NOT report amounts for which another third party or a patient can be billed (e.g., amounts due from patients or "Medigap" payers for co-payments) as adjustments. Reduce these amounts from the initial charges to the primary payer and record or reclassify them as charges due from the secondary source of payment.
Column E: Sliding Fee Discounts
Processes detailed in the health center's sliding fee discount policies and procedures determine the discounts, if any, to apply to the portions of charges owed by patients. Only patients may be granted a sliding fee discount based on their ability to pay.
· Report reductions to patient charges based on the patient's ability to pay using patient's income and family size.
· Include sliding discounts applied to co-payments and deductibles, as applicable. · Report prompt pay discounts provided under a hardship fee waiver program as a sliding fee discount. DO NOT report: · automatic discounting of charges for specific categories of patients (e.g., students, patients experiencing
homelessness, or agricultural workers). · bad debt write-off or forgiveness as a sliding fee discount. · other types of discounts that DO NOT meet the criteria as a sliding fee discount. Note: Column E is grayed out on all third-party payer lines and only available on the self-pay line.
When a sliding fee discount is used to write off part of a charge originally made to a third party, such as Medicare or a private insurance company's co-payment or deductible, first reclassify the charge to self-pay.
To reclassify, first reduce the third-party charge by the amount due from the patient and then increase the self-pay charges by the same amount.
Column F: Bad Debt Write-Off
Bad debt write-off may occur due to the health center's inability to locate patients, a patient's refusal to pay, a patient's inability to pay when their income is greater than 200 percent of the poverty guideline, or a patient's inability to pay even after the sliding fee discount is granted.
· Report amounts billed to and defaulted on by any patient. Report bad debts only from patients. · DO NOT report the bad debt associated with third parties, which may include charges that were not billed
within the time permitted by the payer, charges for services rendered to insured patients by providers who were not credentialed by that payer, charges due from payers who are bankrupt, and similar bad debts. These are not currently reported on the UDS.
Total Patient Service Revenue (Line 14)
Sum of Lines 3 + 6 + 9 + 12 + 13.
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FAQS FOR TABLE 9D
1. How should charges and collections for patients enrolled in an indigent care program be handled? Report such charges as Self-Pay, Line 13, in Column A.
Report the payments, whether made on a per-visit basis or as a lump sum for services rendered, on Line 6a of Table 9E. See Table 9E Cross-Table Reporting Guidance for Indigent Programs for specific instructions.
DO NOT report on this table payments received from state or local indigent care programs subsidizing services rendered to patients who are uninsured.
DO NOT report anything as an indigent care program without first reviewing this in a UDS Training Program, with your UDS Reviewer, or with the UDS Support Center.
2. Should the charges less collections less adjustments equal zero? No, normally this is not equal to zero. Charges (Column A) minus collections (Column B) minus adjustments (Columns D, E, and F) equals the change in accounts receivable or the amount by which what is owed to the health center increases or decreases during the calendar year, except on straight capitation plans only (Lines 2a, 5a, 8a, and 11a). The adjustments for these plans will generally equal the difference between the charges for capitated services and capitations received, unless more is owed to the health center.
3. If we have not received any reconciliation payments for the calendar year, what do we report in Column c1 (current year reconciliations)? Only those cost report settlements and wraparound reconciliations attributable to the report calendar year are reported in Column c1, so nothing would be reported in Column c1.
4. We often use our sliding fee discount program to write off the co-payment portion of the Medicare charge for our certified low-income patients. The sliding fee discount column (Column E) is grayed out for Medicare. How do we record this write-off? Remove the amount of the co-payment from the charge column of the Medicare line (Lines 46, as appropriate), and then add it to the Self-Pay line (Line 13). It can then be written off as a sliding fee discount on Line 13. Use the same process for any other co-payment or deductible write-off for patients who received a sliding fee discount.
5. Our system does not automatically reclassify amounts due from other carriers or from the patient. Must we, for example, reclassify Medicare charges that become co-payments or Medicaid charges? Yes. Regardless of whether it is done automatically by your PMS/HIT/EHR or manually, reflect this reclassification of charges that end up being the responsibility of a party other than the initial party. As a rule, your system will make this adjustment in some way, but you may need to work with your vendor to get a report on the amounts transferred.
6. How do we report the charges and collections for pharmaceuticals dispensed at our contract pharmacies? We discuss contract pharmacy reporting at length in Appendix B. In general, report the full charge in Column A by payer. Then, report the amount received from the patient (on Line 13) or insurance company (on Line 10) in Column B. Report the amount that is written off for an insurance company in Column D. Report the amount written off for a patient as a sliding fee discount in Column E. Similar rules apply if drugs are billable to Medicaid and Medicare.
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UDS SUPPORT CENTER, 866-UDS-HELP, UDSHELP330@BPHCDATA.NET 7. How should we report the charges associated with "G-codes"?
G-codes specify a reimbursement rate associated with a package of services that your health center has described to Medicare. (Similar amounts may be paid to you by other third-party payers as well.) For UDS, report these in: · Column A: The sum of actual fee schedule/CPT-related charges for visits · Column B: What your health center received for payment · Column D: The discounted amount disallowed between charges and the amount received Remember to reduce the charges by the Medicare co-payment (20 percent of the allowable charge). The payment from Medicare will be similarly adjusted. See discussion of reclassifying co-payments. Note: If both the actual charge and the G-code charge are routinely used in your system, you must remove the G-code charges by running a report to get the total for G-code charges for the year and then subtracting this number from the total charges (actual plus G-code). Report the difference in Column A. Reduce Column D by the G-code amount if it was adjusted using a similar process.
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TABLE 9D: PATIENT SERVICE REVENUE
Calendar Year: January 1, 2021, through December 31, 2021
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Line
1 2a 2b 3 4 5a 5b 6 7
8a
8b 8c
Payer Category
Medicaid Non-Managed Care
Medicaid Managed Care (capitated) Medicaid Managed Care (feefor-service)
Total Medicaid (Sum of Lines 1 + 2a + 2b)
Medicare Non-Managed Care
Medicare Managed Care (capitated) Medicare Managed Care (feefor-service)
Total Medicare (Sum of Lines 4 + 5a + 5b) Other Public, including NonMedicaid CHIP, Non-Managed Care Other Public, including NonMedicaid CHIP, Managed Care (capitated) Other Public, including NonMedicaid CHIP, Managed Care (fee-for-service)
Other Public, including COVID-19 Uninsured Program
Full Charges
This Period
(a)
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Amount Collected
This Period
(b)
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Retroactive Settlements, Receipts, and Paybacks (c)
Collection of Reconciliation/ Wraparound Current Year
(c1)
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Collection of Reconciliation/ Wraparound Previous Years
(c2)
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Collection of Other
Payments: P4P, Risk Pools, etc.
(c3)
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Penalty/ Payback
(c4)
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Adjustments (d)
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Sliding Fee Discounts
(e)
[not reported]
Bad Debt Write -Off
(f)
[not reported]
[not reported]
[not reported]
[not reported]
[not reported]
[not reported]
[not reported]
[not reported]
[not reported]
[not reported]
[not reported]
[not reported]
[not reported]
[not reported] [not reported]
[not reported] [not reported]
[not reported]
[not reported]
[not reported]
[not reported]
[not reported]
[not reported]
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Line
9 10 11a 11b 12 13 14
Payer Category
Total Other Public (Sum of Lines 7 + 8a + 8b + 8c)
Private Non-Managed Care Private Managed Care (capitated) Private Managed Care (fee-forservice)
Total Private (Sum of Lines 10 + 11a + 11b)
Self-Pay
Full Charges
This Period
(a)
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Amount Collected
This Period
(b)
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TOTAL (Sum of Lines 3 + 6 + 9 + 12 +
13)
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Retroactive Settlements, Receipts, and Paybacks (c)
Collection of Reconciliation/ Wraparound Current Year
(c1)
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Collection of Reconciliation/ Wraparound Previous Years
(c2)
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Collection of Other
Payments: P4P, Risk Pools, etc.
(c3)
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Penalty/ Payback
(c4)
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[not reported] [not reported] [not reported] [not reported] [not reported] [blank for demonstration]
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Adjustments (d)
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Sliding Fee Discounts
(e)
[not reported]
Bad Debt Write -Off
(f)
[not reported]
[not reported] [not reported] [not reported] [not reported] [blank for demonstration] [blank for demonstration]
[not reported]
[not reported]
[not reported]
[not reported]
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Note: Table 9D Cross-Table Considerations:
· Charges and collections by payer on Table 9D relate to insurance enrollment on Table 4. See the crosswalk of comparable fields in Appendix B. For example, dividing Medicaid revenue on Table 9D, Line 3, Column B by Total Medicaid Patients on Table 4, Line 8 equals the average collection per Medicaid patient.
· Other Public on Table 9D should be consistent with Table 4 except that Other Public categorical grants such as Title X and BCCCP are not insurance and the patients are usually classified as Uninsured on Table 4.
· Managed care revenue on Table 9D relates to member months on Table 4. Dividing managed care capitation revenue by member months equals average capitation per member per month (PMPM). For example, dividing Medicaid capitated revenue (Table 9D, Line 2a, Column B) by Table 4, Line 13a, Column A equals Medicaid PMPM.
· Billable visits reported on Table 5 should relate to patient charges reported on Table 9D.
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Instructions for Table 9E: Other Revenue
Table 9E collects revenue-related non-patient receipts, including grants, contracts, and other funds received in the calendar year from sources within the scope of project. "Grants and contracts" are defined as all amounts received that are not tied to the delivery of patient services.
A new line has been added to report COVID-19-related funding under BPHC.
TABLE 9E: OTHER REVENUE
This table provides information about the health center program's receipt of funds used to support in-scope activities not reported elsewhere.
· Report all non-patient-service-related funds received during the calendar year that supported the federally approved scope of project.
· Use the "last party rule" to classify the receipts. The "last party rule," for UDS reporting purposes, means that grant, contract, and other funds should always be reported based on the entity from which the health center received them, regardless of the source from which they originated.
· DO NOT report any receipts on both tables, as this will duplicate and overstate the cash revenue received. Note: Tables 9D and 9E receipts are summed to equal total cash revenue received in the calendar year.
BPHC GRANTS
Health Center Program Grants, Lines 1a through 1e
· Report drawdowns received during the calendar year for the Health Center Program (section 330) grant, including: o Amounts consistent with the Payment Management System (PMS)-272 federal cash transaction report. Report grant drawdowns as follows: MHC on Line 1a CHC on Line 1b HCH on Line 1c PHPC on Line 1e o Supplemental funding (with the exception of COVID-19) from HRSA is provided as part of the 330 grant. Report these grant funds on the appropriate 330 grant Lines 1a1e, as specified in the health center Notice of Award. o Direct funding, including NAP or expansion funds, only on these lines. o Amounts that the health center received and passed through to another Health Center Program awardee.
· DO NOT reduce the drawdown by the amount the health center passed through to another health center, including sub-awardees or sub-recipients.
· If you are a look-alike or BHW primary care clinic, DO NOT report grant receipts from the BPHC Health Center Program on these lines. The fields are greyed out in the EHBs.
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Total Health Center Program (Line 1g)
Sum of Lines 1a through 1e.
Capital Development Grants (Line 1k)
· Report the amount of Capital Development Grant dollars drawn down. · Include funds from the Health Center Program facility program, as well as funds from the HRSA-
administered school-based health center capital grant program. · Report Capital Assistance for Hurricane Response and Recovery Efforts (CARE) and other funds awarded by
HRSA to assist in the reconstruction and repair of facilities destroyed or damaged by natural disasters.
COVID-19 Supplemental Funding
Lines 1l through 1p · Report drawdowns received during the calendar year for COVID-19 supplemental funding, including:
o Amounts consistent with the PMS-272 federal cash transaction report. Report grant drawdowns as follows: Coronavirus Preparedness and Response Supplemental Appropriations Act (activity code H8C) on Line 1l Coronavirus Aid, Relief, and Economic Security (CARES) Act (activity code H8D) on Line 1m Expanding Capacity for Coronavirus Testing (activity code ECT) on line 1n American Rescue Plan on line 1o Other COVID-19-related funding from BPHC on Line 1p. Use the "specify" field to detail the names and amounts of other COVID-19-related funding from HRSA.
Total COVID-19 Supplemental (Line 1q) Sum of Lines 1l through 1p.
Total BPHC Grants (Line 1)
Sum of Lines 1g + 1k + 1q.
OTHER FEDERAL GRANTS
Ryan White Part C--HIV Early Intervention Grants (Line 2)
· Report drawdowns received during the calendar year for Ryan White Part C cash receipts. · Guidance for reporting other sources of Ryan White funds is provided in the FAQs for Table 9E.
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Other Federal Grants (Line 3)
Federal grants include only those funds received directly by the health center from the U.S. Treasury for which there is a Notice of Federal Award. The most common "other federal" grants reported are from the Office of Minority Health (OMH), the Indian Health Service (IHS), the Department of Housing and Urban Development (HUD), and the Substance Abuse and Mental Health Services Administration (SAMHSA).
· Report drawdowns received during the calendar year for any other federal grants that are within the scope of project. Use the "specify" field to detail the names and amounts of other federal grants.
· Include IHS funds (not including PL 93-638 Compact funds) if your health center is dually funded as an IHS/HRSA-funded health center. Report PL 93-638 Compact funds on Line 6a, Indigent Care.
Medicare and Medicaid EHR Incentive Grants for Eligible Providers (Line 3a)
CMS provides incentives to Eligible Providers (as defined by CMS) for the adoption, implementation, upgrading, and improvement of interoperability of certified EHRs.
· Report grants funded through CMS from the Medicare and Medicaid EHR Incentive Program (now known as "Promoting Interoperability programs").
· In rare cases, these payments go directly to the health center's providers, but they are most commonly paid to the providers' designee (generally, the health center). It is presumed that if the payment goes to the providers these funds will be turned over to the health center. Report them on this line even though the payment may come from the provider and not directly from CMS. This is an exception to the "last party" rule. In the event the provider retains some or all of these grants as part of their compensation, report the total amount on this line and the amount retained by the provider on Table 8A, Line 1, as personnel compensation.
Provider Relief Fund (Line 3b)
· Report funds from the CARES Act Provider Relief Fund through HHS. These funds provide relief to eligible providers for health carerelated expenses or lost revenues that are attributable to the novel coronavirus.
Total Other Federal Grants (Line 5)
Sum of Lines 2 + 3 + 3a + 3b.
NON-FEDERAL GRANTS OR CONTRACTS
State Government Grants and Contracts (Line 6)
· Report drawdowns received during the calendar year for any state government grants or contracts that are within the scope of project and for which the health center receives funds with no specific tie to services provided. Use the "specify" field to detail the names and amounts of state government grants and contracts.
· Most include line-item budgets that support specific personnel positions or other costs. · DO NOT report receipts from state governments that pay based on the amount of health care services
provided or on a negotiated fee-for-service or fee-per-visit. Report charges, collections, and adjustments on Table 9D as Other Public services.
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State/Local Indigent Care Programs (Line 6a)
· Report the amount of funds received from state/local indigent care programs that are earmarked to subsidize services rendered to patients who are uninsured. Use the "specify" field to detail the names and amounts of state/local indigent care programs.
· Revenue is received as a grant amount, rather than on a fee-for-service basis. · Include amounts allocated to the health center by tribes from their IHS PL 93-638 Compact funds. · DO NOT include revenue received under a contract with a tribal government for services provided to its
members. Report as Other Public with charges, collections, and adjustments on Table 9D. · Further guidance is available in Appendix B.
Local Government Grants and Contracts (Line 7)
· Report drawdowns received during the calendar year for any local government grants or contracts that are within the scope of project and for which there is no specific tie to patient services provided. Use the "specify" field to detail the names and amounts of local government grants and contracts.
· Most include line-item budgets that support specific personnel positions or other costs. · DO NOT include revenue received from local governments that pay based on amount of health care services
provided or on a negotiated fee-for-service or fee per visit. Report charges, collections, and adjustments on Table 9D as Other Public services. · DO NOT include funds from local indigent care programs here. Report these on Line 6a.
Foundation/Private Grants and Contracts (Line 8)
· Report the amount received from foundations or private organizations during the calendar year that covers costs included within the scope of project. Use the "specify" field to detail the names and amounts of foundation/private grants and contracts.
· Include funds received from a primary care association, another health center, or another community service provider on this line, regardless of the funds' origin.
Total Non-Federal Grants and Contracts (Line 9)
Sum of Lines 6 + 6a + 7 + 8.
Other Revenue (Line 10)
· Report other revenue receipts included in the federally approved scope of project that are unrelated to chargebased services or to grants and contracts described above. Use the "specify" field to detail the names and amounts of other revenue.
· Include fundraising, interest revenue, rent from tenants, patient health records fees, individual monetary donations, receipts from vending machines, pharmacy sales to the public (i.e., nonhealth center patients), etc.
· Include receipts related to the gain on the sale of an asset.
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DO NOT report: · the value of in-kind or other non-monetary donations made to the health center. Report these only on Table
8A, Line 18. · the proceeds of any loan received for operations, a mortgage, or other purposes. · insurance proceeds related to a loss, unless the loss was recognized as an expense rather than a reduction in
the value of an asset. · the receipt or recognition of in-kind "community benefit" from a third party here or anywhere else on the
UDS unless it is received as a cash donation. · under any circumstances, payments or net payments from a pharmacy contracted to dispense 340B
pharmaceuticals on this line (or anywhere on Table 9E). Report all revenue from pharmacy services provided to patients on Table 9D, and record all expenses on Table 8A.
Total Other Revenue (Line 11)
Sum of Lines 1 + 5 + 9 + 10.
FAQS FOR TABLE 9E
1. We received maternal and child health services funds from the state that originated from the federal government. On which line do we report these funds? Use the last party rule to report on this table. In this instance, report these funds as state grants, since the funds were awarded to the health center by the state for maternal and child health services, even though these may include a mixture of federal funds (such as Title V) and state funds.
2. We receive various Ryan Whiterelated funds. How do we report these? This depends on which entity you received Ryan White funds from. Use the following to guide your reporting: · Report Ryan White Part A, Impacted Area grants, from county or city governments on Line 7. If they are first sent to a third party, report the funds on Line 8. Report on Line 3 when the reporting entity is a county or city government and the funds were received directly from the Ryan White Part A federal program. · Report Part B grants from the state on Line 6, unless they are first sent to a county or city government (in which case, report on Line 7) or to a third party (in which case, report the funds on Line 8). · Report drawdowns received during the calendar year for Ryan White Part C cash receipts on Line 2. · Report Part D funds from the HIV/AIDS Bureau on Line 3. · Report Part F funds, Special Projects of National Significance grants, received from the HIV/AIDS Bureau on Line 3.
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UDS SUPPORT CENTER, 866-UDS-HELP, UDSHELP330@BPHCDATA.NET 3. Are there any important issues to keep in mind for this table?
This table collects information on cash receipts for the calendar year that supported activities described in the scope of project covered by any of the Health Center Program awards, the look-alike designation, or the BHW primary care clinics program. In the case of a grant: · Report the cash amount received during the calendar year. · DO NOT report the award amount (unless the full award was paid/drawn down during the year). 4. How should we report indigent care funds? · Report payments received from state or local indigent care programs subsidizing services rendered to
patients who are uninsured (including patients covered by a tribe's 638 funds) on Line 6a of Table 9E, whether the actual payment to the health center is made on a per-visit basis or as a lump sum for services rendered. · Report patients covered by these programs as Uninsured on Table 4. · Report all charges, self-pay patient collections, sliding fee discounts, and bad debt write-offs on the SelfPay line (Line 13) on Table 9D. · Report amounts collected from the patients covered by indigent programs on Table 9D. However, DO NOT report funds reported on Line 6a of Table 9E on Table 9D as collections, sliding discounts, or bad debt.
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TABLE 9E: OTHER REVENUES
Calendar Year: January 1, 2021, through December 31, 2021
Line Source
Amount (a)
[blank] BPHC Grants (Enter Amount Drawn Down--Consistent with PMS 272)
[blank]
1a Migrant Health Center
[blank]
1b Community Health Center
[blank]
1c Health Care for the Homeless
[blank]
1e Public Housing Primary Care
[blank]
1g
Total Health Center (Sum of Lines 1a through 1e) [blank]
1k
Capital Development Grants, including School-Based Health Center Capital Grants [blank]
1l Coronavirus Preparedness and Response Supplemental Appropriations Act (H8C)
[blank]
1m Coronavirus Aid, Relief, and Economic Security Act (CARES) (H8D)
[blank]
1n Expanding Capacity for Coronavirus Testing (ECT) (H8E and LAL ECT)
[blank]
1o American Rescue Plan
[blank]
1p Other COVID-19-Related Funding from BPHC (specify_______)
[blank]
1q
Total COVID-19 Supplemental (Sum of Lines 1l through 1p) [blank]
1
Total BPHC Grants [blank]
(Sum of Lines 1g + 1k + 1q)
[blank] Other Federal Grants
[blank]
2
Ryan White Part C HIV Early Intervention
[blank]
3
Other Federal Grants (specify _______)
[blank]
3a Medicare and Medicaid EHR Incentive Payments for Eligible Providers
[blank]
3b Provider Relief Fund (specify _______)
[{blank]
5
Total Other Federal Grants [blank]
(Sum of Lines 2 through 3b)
[blank] Non-Federal Grants or Contracts
[blank]
6
State Government Grants and Contracts (specify_______)
[blank]
6a State/Local Indigent Care Programs (specify_______)
[blank]
7
Local Government Grants and Contracts (specify_______)
[blank]
8
Foundation/Private Grants and Contracts (specify_______)
[blank]
9
Total Non-Federal Grants and Contracts [blank]
(Sum of Lines 6 + 6a + 7 + 8)
10 Other Revenue (nonpatient service revenue not reported elsewhere) (specify ______) [blank]
11
Total Revenue (Sum of Lines 1 + 5 + 9 + 10) [blank]
Note: Table 9E Cross-Table Considerations:
· Only public pharmacy revenue is reported on Table 9E. Follow the guidance for other pharmacy reporting situations as described in Appendix B.
· The revenue received from indigent care programs that subsidize services rendered to patients who are uninsured are reported on Table 9E, while the charges for these services are reported on Table 9D. Follow the detailed reporting requirements included in Appendix B to address the cross-table reporting.
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Appendix A: Listing of Personnel
All line numbers in the following table refer to Table 5. Not all services delivered by a "provider" count as visits. DO NOT count encounters with "non-providers" as countable visits. Use the Provider definitions to classify personnel as a "provider" or "non-provider."
Personnel by Major Service Category Physicians Family practitioners (Line 1) General practitioners (Line 2) Internists (Line 3) Obstetricians/Gynecologists (Line 4) Pediatricians (Line 5) Licensed medical residents--line determined by specialty Other Specialist Physicians (Line 7) Allergists Cardiologists Dermatologists Endocrinologists Orthopedists Surgeons Urologists Other specialists and sub-specialists Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives Nurse practitioners (Line 9a) Physician assistants (Line 9b) Certified nurse midwives (Line 10) Nurses (Line 11) Clinical nurse specialists Public health nurses Home health nurses Visiting nurses Registered nurses (RNs) Licensed practical nurses/Licensed vocational nurses Nurse emergency medical services (EMS)/Nurse emergency medical technicians (EMT) Other Medical Personnel (Line 12) Nurse aides/assistants (certified and uncertified) Clinic aides/medical assistants (certified and uncertified medical technologists) Unlicensed interns and residents EMS/EMT personnel (not credentialed as a nurse) Laboratory Personnel (Line 13) Pathologists Medical technologists Laboratory technicians Laboratory assistants Phlebotomists X-Ray Personnel (Line 14) Radiologists X-ray technologists X-ray technicians Radiology assistants Ultrasound technicians
Provider <blank>
X X X X X X <blank> X X X X X X X X <blank> X X X <blank> X X X X X <blank>
X
<blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank>
Non-Provider <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> X
blank
<blank> X X X X
<blank> X X X X X
<blank> X X X X X
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Personnel by Major Service Category Dentists (Line 16) General practitioners Oral surgeons Periodontists Endodontists Other Dental
Dental hygienists (Line 17) Dental therapists (Line 17a) Dental assistants, advanced practice dental assistants (Line 18) Dental technicians (Line 18) Dental aides (Line 18) Dental students (including hygienist students) (Line 18) Mental Health (Line 20) and Substance Use (Line 21) Psychiatrists (Line 20a) Psychologists (Line 20a1) Social workers--clinical (Line 20a2 or 21) Social workers--psychiatric (Line 20b or 21) Family therapists (Line 20b or 21) Psychiatric nurse practitioners (Line 20b) Nurses--psychiatric and mental health (Line 20b) Unlicensed mental health providers, including trainees (interns or residents) and "certified" personnel (Line 20c) Unlicensed substance use disorder providers, including trainees (interns or residents) and "certified" personnel (Line 21) Alcohol and drug abuse counselors (Line 21) RN counselors (Line 20b or 21) All Other Professional Personnel (Line 22)
Audiologists Acupuncturists Chiropractors Community health aides and practitioners Herbalists Massage therapists Naturopaths Registered dietitians, including nutritionists/dietitians Occupational therapists Podiatrists Physical therapists Respiratory therapists Speech therapists/pathologists
Traditional healers Vision Services Personnel Ophthalmologists (Line 22a) Optometrists (Line 22b) Ophthalmologist/optometric assistants (Line 22c) Ophthalmologist/optometric aides (Line 22c) Ophthalmologist/optometric technicians (Line 22c) Pharmacy Personnel (Line 23) Pharmacists, clinical pharmacists Pharmacy technicians Pharmacist assistants Pharmacy clerks
Provider <blank>
X X X X <blank> X X <blank> <blank> <blank> <blank> <blank> X X X X X X X
X
X
X X
X X X X X X X X X X X X X X <blank> X X <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank>
Non-Provider <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> X X X X <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank>
<blank>
<blank>
<blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank>
X X X <blank> X X X X
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Personnel by Major Service Category Enabling Services Case Managers (Line 24) Case managers Care/referral coordinators Patient advocates Social workers Public health nurses Home health nurses Visiting nurses Registered nurses Licensed practical nurses/licensed vocational nurses Health Educators (Line 25) Family planning counselors Health educators Social workers Public health nurses Home health nurses Visiting nurses Registered nurses Licensed practical nurses/licensed vocational nurses Outreach Workers (Line 26) Outreach workers Patient Transportation Workers (Line 27) Patient transportation coordinators Drivers, including mobile van drivers Eligibility Assistance Workers (Line 27a) Benefits assistance workers Pharmacy assistance program (PAP) eligibility workers Eligibility workers Patient navigators Patient advocates Registration clerks Certified assisters Interpretation (Line 27b) Interpreters Translators Community health workers Community health advisors or representatives Lay health advocates Promotoras Other Enabling Services Personnel (Line 28) Other enabling services personnel
Provider <blank> <blank>
X X X X X X X X X <blank> X X X X X X X X <blank>
<blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank>
Non-Provider <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> X <blank> X X <blank> X X X X X X X <blank> X X X X X X <blank> X
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Personnel by Major Service Category Other Program-Related Services Personnel (Line 29a) WIC workers Head Start workers Housing assistance workers Child care workers Food bank/meal delivery workers Employment/educational counselors Exercise trainers/fitness center personnel Adult day health care, frail elderly support personnel Quality Improvement Personnel (QI) (Line 29b)
QI nurses
QI technicians
QI data specialists
Statisticians, analysts
Quality assurance/quality improvement and HIT/EHR design and operation personnel Management and Support Personnel (Line 30a)
Project directors Chief executive officers/executive directors Chief financial officers/fiscal officers Chief information officers Chief medical officers Secretaries/administrative assistants Administrators Directors of planning and evaluation Clerk typists Personnel directors Receptionists Directors of marketing Marketing representatives Enrollment/service representatives Fiscal and Billing Personnel (Line 30b) Finance directors Accountants Bookkeepers Billing clerks Cashiers Data entry clerks IT Personnel (Line 30c) Directors of data processing Programmers IT help desk technicians Data entry clerks Facility (Line 31) Janitors/custodians Security guards Groundskeepers Equipment maintenance personnel Housekeeping personnel
Provider <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank>
<blank>
<blank>
<blank>
<blank>
<blank>
<blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank>
Non-Provider <blank> X X X X X X X X <blank>
X
X
X
X
X
<blank> X X X X X X X X X X X X X X
<blank> X X X X X X
<blank> X X X X
<blank> X X X X X
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Personnel by Major Service Category Patient Services Support Personnel (Line 32) Medical and dental team clerks Medical and dental team secretaries Medical and dental appointment clerks Medical and dental patient health records clerks Patient health records supervisors Patient health records technicians Patient health records clerks Patient health records transcriptionists Registration clerks Appointments clerks
Provider <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank> <blank>
Non-Provider <blank> X X X X X X X X X X
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Appendix B: Special Multi-Table Situations
Several conditions require special consideration in the UDS because they affect multiple tables that must then be reconciled. This appendix presents some situations along with instructions on how to deal with them, including: · Contracted care (specialty, dental, mental health, etc.) that is paid for by the reporting health center · Services provided by a volunteer provider · Interns and residents · WIC · In-house pharmacy or dispensary services for health center patients · In-house pharmacy for community (i.e., for non-patients) · Contract pharmacies · Donated drugs · Clinical dispensing of drugs · ADHC/PACE · Medi-Medi crossovers · Certain grant-supported clinical care programs (BCCCP, Title X, etc.) · State or local indigent care programs · Workers' compensation · Tricare, Trigon, Public Employees Insurance, etc. · Contract sites · CHIP · Carved-out services · Incarcerated patients · HIT/EHR personnel and costs · Migrant voucher programs and other voucher programs · New start or new access point · Relationship between personnel on Table 5 and costs on Table 8A · Relationship between insurance on Table 4 and revenue on Table 9D · Relationship between prenatal care on Table 6B and deliveries on Table 7 · Relationship between race and ethnicity on Table 3B and Table 7
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CONTRACTED CARE (SPECIALTY, DENTAL, MENTAL HEALTH, ETC.)
Contracted care is services paid for by the health center.
Tables Affected
Treatment
Report providers (Column A) if the contract is for a portion of an FTE (e.g., one-day-a-week OB/GYN = 0.20 FTE).
5
Always report visits (Column B or B2), regardless of method of provider payment or location of service (health center's service delivery site or contract provider's office).
6A 6B, 7
8A
DO NOT report FTE if the contract is for a service (e.g., $X per visit or $55 per resource-based relative value unit [RBRVU]). Report diagnoses and/or services provided, as applicable, from the encounter form or equivalent from received from the contract provider. If a contract provider provides any services that are subject to clinical quality measures, collect and report all data from contractor (e.g., birth weight of a baby from contract obstetrician, last HbA1c from an endocrinologist, sealants placed from a dentist). Column A, Accrued Cost: Report cost of provider/service on the applicable line. If the provider receives a "co-payment" or a "nominal fee" from the patient, report the sum of that and what the health center pays.
Column B, Facility and Non-Clinical Support Services: The health center will generally use a lower facility and non-clinical support services allocation rate for off-site services. Include all facility and non-clinical support costs in the direct charge (Column A) if the provider is off-site. Column A, Charge: The health center's UCR charge if on-site; use the contractor's UCR charge if off-site.
Column B, Collection: The amount received by either the health center or contractor from first or third parties.
9D
Column D, Adjustment: The amount disallowed by a third party for the charge (if on Lines 112).
Column E, Sliding Fee Discount: The amount written off for eligible patients per the health center's fiscal policies (Line 13), if applicable. Calculate as UCR charge, minus amount collected from patients, minus amount owed by patients as their share of payment. DO NOT include payment by the health center here.
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SERVICES PROVIDED BY A VOLUNTEER PROVIDER
Volunteers are not paid by the health center for services, which they provide on-site. This includes volunteer personnel (including AmeriCorps/HealthCorps, but not NHSC) who provide services on- or off-site on behalf of the health center. FTE can be included in the UDS Report when there is a basis for determining their hours.
Tables Affected
5
Treatment
Column A, FTE: Report FTE for services provided by volunteers on-site at the health center's service delivery site. FTE must be calculated. Use hours volunteered as the numerator. Because volunteers DO NOT receive paid leave benefits, the denominator is the number of hours that comparable personnel spend performing their job. Reduce a full-time schedule of 2,080 hours (for example) by vacation, sick leave, holidays, and continuing education normally provided to personnel. As a rule of thumb, use hours worked divided by a number somewhere around 1,800.
DO NOT report providers who provide services at their own offices.
Column B, Clinic Visits, and Column B2, Virtual Visits: Count visits only for services provided at a service
delivery site in the health center's scope of project and under its control.
6A
Report diagnoses and/or services provided on-site, as applicable.
8A
Column C, Line 18: Report the value of the time donated by volunteers on this line only.
The charges for their services are treated the same as for personnel if the provider is on-site.
9D
DO NOT include charges for volunteer providers who are off-site.
INTERNS AND RESIDENTS
Health centers often use individuals who are in training, referred to variously as interns or residents depending on their field and their licensing. Medical residents are generally licensed practitioners. Some mental health interns, as well as other providers, may be licensed practitioners who are training for a higher level of certification or licensing.
Tables Affected
5
Treatment
Column A: Report licensed interns and residents in the credentialing category they are pursuing. For example, count a family practice resident on Line 1 as a Family Physician. Depending on the arrangement, FTEs may be calculated like any other personnel (if they are being paid by the health center) or like a volunteer (if they are not being paid). See volunteer providers above.
Columns B and B2: Report visits between a medical resident and a patient as visits to that resident or intern.
DO NOT credit the visits to the supervisor of the resident or intern under any circumstance.
If the intern or resident is paid by the health center or their cost is being paid through a contract that pays a
third party for the interns or residents, report the cost in Column A on the appropriate line (Line 1 for
8A
medical, Line 5 for dental, etc.).
If the health center is not paying an intern, resident, or third party, report the value of the donated time on Line 18. Be sure to describe the nature of the donation on the table.
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WOMEN, INFANTS, AND CHILDREN (WIC)
Tables Affected
Treatment
3A, 3B, 4
DO NOT report individuals whose only encounter with the health center is for WIC services (e.g., nutrition, health education, enabling services) and who receive no other services listed on Table 5 from providers outside of WIC.
Report FTE (Column A) on Line 29a. 5
DO NOT report visits and patients (Columns B, B2, and C).
Column A, Accrued Cost: Report the total net accrued cost of the program on Line 12 in Column A.
8A
Column B, Allocation of Facility and Non-Clinical Support Services: Since much of the non-clinical support
services cost of the program will be included in the direct costs, it is presumed that overhead will be at a
significantly lower rate.
9D
DO NOT report anything associated with the WIC program.
Revenue for WIC programs, though originally federal, generally comes to health centers from the state,
9E
though some receive it from a lower-level intermediary. If the health center is receiving WIC funds from a state government, the grant/contract funds received go on Line 6. Report funds from an intermediary on Line
8.
IN-HOUSE PHARMACY OR DISPENSARY SERVICES FOR HEALTH CENTER PATIENTS
Include only that part of the pharmacy that is paid by the health center and dispensed by in-house personnel (see below for other situations).
Tables Affected
5
Treatment
Column A, FTE: Report pharmacy personnel on Line 23. If they have only an incidental responsibility to provide assistance in enrolling patients in PAPs, include them on Line 23. Include clinical pharmacists on Line 23 even if they spend time outside of the pharmacy. Report personnel other than pharmacists who spend time with PAPs on Line 27a, Eligibility Assistance.
Columns B and B2, Visits: The UDS does not count encounters with pharmacy personnel as visits, whether it is for filling prescriptions or associated education or other patient/provider support. This is true for clinical pharmacists with expanded clinical privileges, as well. Line 8a, Column A, Other Pharmacy Direct (Accrued) Costs: Report all other operating costs of the pharmacy on Line 8a. Include salaries, benefits, pharmacy computers, supplies, etc.
Line 8b, Column A, Pharmaceutical Direct (Accrued) Costs: Place the actual cost of drugs the pharmacy bought on Line 8b. Include the cost of vaccines, contraceptives, injectable antibiotics, and other drugs dispensed in the health center but not in a pharmacy on Line 8b. The value of donated drugs is not reported here. That amount is reported on Line 18 in Column C.
Line 11e, Column A, Eligibility Assistance Direct (Accrued) Costs: Report on Line 11e the cost of personnel
8A
(full-time, part-time, or allocated time) helping patients become eligible for PAPs and of all related supplies,
equipment depreciation, etc.
Column B, Facility and Non-Clinical Support Services: Report all facility and non-clinical support services costs associated with pharmacy and pharmaceuticals (Lines 8a and 8b) on Line 8a. Although there may be some facility and non-clinical support services costs associated with the actual purchase of the drugs, these costs are generally minimal when compared to the total cost of the drugs.
Column C, Line 18: Report the value of donated drugs, including vaccines (generally calculated at 340B rates), on this line only.
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Tables Affected
9D
9E
Treatment Column A: Charge is the health center's full retail charge for dispensed drugs.
Column B: Collection is the amount received from patients or other third parties/insurance companies.
Column D: Adjustment is the amount a third party disallows for the charge (if on Lines 112).
Column E: Sliding fee discount is the amount written off for eligible patients per health center policies (Line 13). Calculate as retail charge, minus amount collected from patients (if any), minus amount owed by patients (if any), as their share of payment. DO NOT report the value of donated drugs on this table; report on Table 8A, Line 18 (see next page, Donated Drugs, Including Vaccines). The charges for drugs dispensed to patients go on Table 9D, not on this table.
IN-HOUSE PHARMACY FOR COMMUNITY (I.E., FOR NON-PATIENTS)
Many health centers that own licensed pharmacies also provide services to members of the community at large who are not health center patients. Careful records must be maintained at these pharmacies to ensure that nonpatients DO NOT receive drugs purchased under section 340B provisions. Some of these pharmacies are totally in scope, while others have their "public" portion out of scope. If the public aspect is out of scope, DO NOT report its activities on the UDS. If it is in scope, treat the public portion as an "other activity," as follows:
Tables Affected 5
8A
9E
Treatment
Column A, FTE: Report allocated public portion of personnel on Line 29a: Other Programs and Services. Line 12: Other Program-Related Services: Report all related personnel and pharmacy costs, including cost of pharmaceuticals. Line 10, Other Revenue: Report all revenue from public pharmacy and specify from "Public access pharmacy."
CONTRACT PHARMACY DISPENSING TO HEALTH CENTER PATIENTS, GENERALLY USING 340B
PURCHASED DRUGS
Tables Affected 5
Treatment
DO NOT report personnel, visits, or patients for pharmacy dispensing. Report the amount the pharmacy charges for managing dispensing of drugs on Line 8a.
Report the full amount paid for pharmaceuticals, either directly by the clinic or indirectly by the pharmacy, on Line 8b.
If the pharmacy buys prepackaged drugs and there is no reasonable way to separate the pharmaceutical costs
8A
from the dispensing/administrative costs, report all costs on Line 8b. Associated non-clinical support services
(overhead) costs will go on Line 8a in Column B, even though Line 8a Column A is blank.
Report payments to pharmacy benefit managers on Line 8a.
Share of profits: Some pharmacies engage in fee splitting and keep a share of profit. Report this as a payment to the pharmacy on Line 8a.
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Tables Affected
9D
9E
Treatment
Column A, Charge: Report the health center/contract pharmacy's full retail charge for the drugs dispensed. If retail is unknown, ask the pharmacy for retail prices for the drugs dispensed.
Column B, Collection: Report the amount received from patients or insurance companies. Health centers must collect this information from the contract pharmacy. (Note: Most health centers DO NOT have this sort of arrangement for Medicaid patients, unless explicitly stated.)
Column D, Adjustment: Report the amount disallowed by a third party for the charge (if on Lines 112).
Column E, Sliding Fee Discount: Report the amount written off for eligible patients per health center policies (Line 13). Calculate as retail charge (or pharmacy charge), minus amount collected from patients (by pharmacy or health center), minus amount owed by patients as their share of payment. DO NOT report pharmacy revenue on Table 9E, and DO NOT use Table 9E to report net revenue from the pharmacy. Report actual gross revenue on Table 9D.
DONATED DRUGS, INCLUDING VACCINES
Tables Affected
8A
Treatment
If the drugs are donated to the health center and then dispensed to patients, report their value (generally calculated at 340B rates) on Line 18, Column C.
If the drugs are donated directly to the patient, the health center is not required to report the value of the drugs; however, it is preferred that the value be included for a better understanding of the program.
9D
If the health center charges patients a dispensing fee, report only this amount and its collection and/or writeoff.
9E
DO NOT report any amount, even though generally accepted accounting principles (GAAP) might suggest another treatment for the value.
CLINICAL DISPENSING OF DRUGS
Clinic areas of health centers dispense many pharmaceuticals, including vaccines, allergy shots, contraceptives, and drugs used in MAT of opiate use. This may be a service associated with the visit or, in the case of vaccinations, a community service. These services DO NOT count as a visit, but charging patients for them is appropriate unless the clinic received the drugs for free.
Tables Affected 3A, 3B, 4 5 6A
8A
9D
9E
Treatment
DO NOT report these individuals as patients if this is the only service they received during the year. DO NOT report these services as visits. DO NOT report these on Table 6A; they are not visits. Report drug costs on Line 8b, Pharmaceuticals (not on Line 3, Other Medical Costs). In the case of vaccines obtained at no cost through Vaccines for Children or other state or local programs, report the value on Line 18, Donated Services and Supplies. Report full charges, collections, adjustments, and discounts, as appropriate. Note that it is not appropriate to charge for a pharmaceutical that has been donated. However, an administration and/or dispensing fee is appropriate. Note that Medicare has separate flu vaccine rules. DO NOT report any amount.
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ADHC AND PACE
Medicare, Medicaid, and certain other third-party payers often recognize ADHC programs. They involve caring for an infirm, frail, or elderly patient during the day to permit family members to work and to avoid institutionalization and preserve the health of the patient. They are quite expensive and may involve extraordinary per member per month (PMPM) capitation payments, but are cost effective compared to institutionalization. Patients who have both Medicare and Medicaid coverage are treated as Medi-Medi, as described below. PACE is even more expansive and may include ADHC services, as well as services to maintain independence for the elderly.
Tables Affected 3A, 3B, 4
5
6A, 6B, 7 8A 9D
Treatment
Report the individuals seen during the year in ADHC and PACE programs as patients if the encounter is a countable visit. When a provider does a formal, separately billable examination of a patient at the ADHC/PACE facility, treat it as any other medical visit.
DO NOT count the nursing, observation, monitoring, and dispensing of medication services that are bundled together to form an ADHC service as a visit for the purposes of reporting. Personnel are included on Line 29a, Other Programs and Services. Report the clinical activity provided to patients at ADHC and PACE facilities, as appropriate, on the clinical tables. If the health center provides and bills medical services separately from the ADHC charge, report the associated costs on Lines 13. Report all other costs on Line 12. Similarly, include PACE costs for medical on Lines 13, pharmacy costs on Lines 8a8b, and all other costs on Line 12. Report ADHC charges and collections on this table, generally as Medicaid and/or Medicare. Because of FQHC procedures, it is possible that there will also be significant positive or negative adjustments. In addition, see Medi-Medi, below.
MEDI-MEDI/DUALLY ELIGIBLE
Some individuals are eligible for and enrolled in both Medicare and Medicaid (commonly referred to as MediMedi or dually eligible). In this case, Medicare is primary and billed first. After Medicare pays its (usually FQHC-associated Z code or geographic-rate-adjusted) fee, the remainder is billed to Medicaid, which pays an amount based on policy that varies from state to state.
Tables Affected 4
9D
Treatment
Report patients on Line 9, Medicare.
DO NOT report as Medicaid. In addition, report these patients on Line 9a, Dually Eligible (Medicare and Medicaid); this line is a subset of the total reported on Line 9, Medicare. While the entire charge initially shows as a Medicare charge, after Medicare makes its payment the remaining allowable amount is reclassified to Medicaid. Report the payment received from Medicaid on Line 1 in Column B. Report the difference between the charge and the collection as a positive or negative adjustment, depending on the amount.
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CERTAIN GRANT-SUPPORTED CLINICAL CARE PROGRAMS: BCCCP, TITLE X, ETC.
Some programs pay providers on a fee-for-service or fee-per-visit basis under a contract, which may or may not also have a cap on total payments per grant period (usually the state fiscal year). They cover a very narrow range of services. Breast and cervical cancer control and family planning programs are the most common, but there are others.
These are fee-for service or fee-per-visit programs only.
Tables Affected 4
9D
9E
Treatment
These programs are not insurance. They pay for a service, but health centers must classify patients according to their primary health insurance carrier. Most of these programs DO NOT serve insured patients, so most of the patients would be reported on Line 7 as uninsured. Although the patient is likely uninsured, there is an "other public" payer for the service. Report the health center's usual and customary charge for the service (not the negotiated fee paid by the public entity) on Line 7 in Column A and the payment in Column B. Because the payment will almost always be different from the charge, report the difference as an adjustment in Column D. DO NOT report the grant or contract covering the fee-for-service or fee-per-visit amount on Table 9E. Fully account for this on Table 9D.
STATE OR LOCAL INDIGENT CARE PROGRAMS
These pay through a grant for a wide range of clinical services for uninsured patients, generally those under an income limit. Most of these programs set payment caps and often make payments in a different fiscal year than that in which the patient received the service.
Tables Affected 4
9D
9E
Treatment
While patients may need to meet eligibility criteria, these programs are not public insurance. Count patients receiving care through these programs on Line 7 as uninsured, unless they have insurance. The health center's usual charges for each service are charged directly to patients (reported on Line 13, Column A). If patients pay any co-payment, report it in Column B. If they are responsible for a co-payment but DO NOT pay it, it remains a receivable until it is collected or is written off as bad debt in Column F. Report the rest of the charge (or all the charge if there is no required co-payment) as a sliding fee discount in Column E. Report the total amount received during the calendar year from the state or local indigent care program on Line 6a.
WORKERS' COMPENSATION
Workers' compensation is a form of liability insurance for employers and not health insurance for employees.
Tables Affected 4
9D
Treatment
If workers' compensation covers a patient's bills, the patient usually has related insurance. Report that on Table 4 (even if the health center is not billing the insurance). Patients with work-related insurance go on Line 11 (Private). Those without any health insurance go on Line 7 (Uninsured). Report charges, collections, and adjustments for workers' compensation-covered services on Line 10 (Private Non-Managed Care).
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TRICARE, TRIGON, PUBLIC EMPLOYEES' INSURANCE, ETC.
Many government employees have insurance.
Tables Affected
4
9D
Treatment
Report them on Line 11 (Private), not on Line 10a. Note: Coverage directly through the Department of Veterans Affairs is a form of "other public" payment, not a form of medical insurance. Identify if the patient has primary medical insurance. Report charges, collections, and adjustments on Lines 1012 (Private), not on Lines 79.
CONTRACT SITES
Some health centers have included in their scope of project a service delivery site (such as a school, workplace, or jail) where they provide services to patients at a contracted flat rate per session or other similar rate that is not based on the volume of work performed. The agreement generally stipulates whether and under what circumstances the health center may bill third parties.
Tables Affected
4
5 8A 9D 9E
Treatment
Lines 16, Income: Obtain information on income from patients. In prisons, assume that all are at 100 percent and below FPG (Line 1). In schools, income should be that of the parent(s) or "unknown." In the case of minor consent services, patients should be reported as below poverty. In the workplace, income is the patient's family income or, if not known, "unknown" (Line 5).
Lines 712, Insurance: Record the form of medical insurance the patient has, regardless of the health center's ability to bill that source. (Medicaid often covers children in school-based clinics even though they have another provider. Report these children as Medicaid patients.) The health center's contracting agency is not an insurer. Except for confidential minor consent services, it is not acceptable to report a student as uninsured. Report all visits as appropriate.
DO NOT reduce or reclassify FTEs for travel time. Costs will generally be considered medical (Lines 13) unless other services (mental health, case management, etc.) are being provided.
DO NOT report on Line 12: Other Related Services. Unless the health center charges a visit to a third party such as Medicaid, report the health center's usual and customary charges on Line 10, Column A (Private). Report the amount paid by the contractor in Column B. Report the difference (positive or negative) in Column D (Adjustments). DO NOT report contract revenue on Table 9E.
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THE CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP)
CHIP provides health coverage to eligible children through Medicaid and separate CHIP programs. CHIP is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.
Tables Affected 4
9D
Treatment
Medicaid: If Medicaid handles CHIP and the enrolled patients are identifiable, report them on Line 8b. If it is not possible to differentiate CHIP administered through Medicaid from Medicaid, report the enrolled patients on Line 8a with all other Medicaid patients.
Non-Medicaid: Report CHIP-enrolled patients in states that DO NOT use Medicaid as "Other Public CHIP" on Line 10b. DO NOT report the enrollees on Line 11 (Private) even if a private insurance plan administers the program. Medicaid: Report on Lines 13, as appropriate.
Non-Medicaid: Report on Lines 79 (Other Public), as appropriate. DO NOT report on Lines 1012 (Private), even if a private insurance company administers the plan.
CARVE-OUTS
Relevant to capitated managed care only: The health center has a capitated contract with an HMO that stipulates that one set of CPT codes will be covered by the capitation, regardless of service frequency, and another set of codes (or all other codes) will be paid for by the HMO on a fee-for-service basis (the carve-outs) when appropriate. Most common carve-outs involve mental health, lab, radiology, and pharmacy, but may include specific specialty care or diagnoses (e.g., perinatal care or HIV).
Tables Affected 4
9D
Treatment
Patient Member Months: Member months are reported on Line 13a in the appropriate column, regardless of whether the patient made use of services in any or all of those months. Make no entry on Line 13b (fee-forservice managed care member months) for the carved-out services, regardless of payments received. Lines 2a/b, 5a/b, 8a/b, 11a/b: Report capitation payments on the "a" lines and carve-out payments on the "b" lines. Report wraparound payments on both lines using the health center's allocation process.
INCARCERATED PATIENTS
Some health centers contract with jails or prisons to provide health services to inmates. These arrangements can vary in terms of the contractual arrangement and location for providing health services to patients.
Tables Affected
4
Treatment Assume prisoner income is at or below 100 percent FPL (Line 1).
Unless the institution has arranged for inmate Medicaid enrollment, assume that inmates are uninsured. The jail or prison pays for the patient's services.
Report the health center's usual and customary charge for the service in Column A and the payment in
9D
Column B. Because the payment will almost always be different from the charge, report the difference as an
adjustment in Column D, as follows:
· Line 9 (Other Public) if a government entity
· Line 10 (Private) if privately run
9E
DO NOT report the grant or contract on Table 9E. Report revenue fully on Table 9D.
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HIT/EHR PERSONNEL AND COSTS
HIT, including EHR systems (some of which have integrated PMS), record clinical activities and help providers manage and integrate patient services. As such, they are part of a QI program, though some aspects count in other service categories.
Tables Affected
Treatment
Include personnel who document services in the HIT/EHR or perform help desk, data entry, training, and technical assistance functions as part of the appropriate service category for which they perform these functions, not as IT personnel or QI personnel.
5
Report personnel members dedicating some or all of their time to design, operation, and oversight of QI
systems; data specialists; statisticians; and HIT/EHR or medical form designers as QI personnel on Line 29b.
Report personnel managing the hardware and software of a practice management billing and collection system as non-clinical support personnel under IT, Line 30c. Report costs for personnel who document services in the HIT/EHR or perform help desk, data entry, training, and technical assistance functions as part of the appropriate service category for which they perform these functions, not as IT personnel or QI personnel.
Report costs associated with licenses, depreciation of the hardware and software, software support services,
8A
and annual fees for other aspects of the HIT/EHR on Line 3 (Other Medical). If the HIT/EHR covers dental and/or mental health, then you may logically allocate some of costs to these lines, as well.
Report costs for personnel noted above as being included in QI on Line 12a.
Report costs for personnel managing the hardware and software of a practice management billing and collection system as non-clinical support, Line 15.
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ISSUANCE OF VOUCHERS FOR PAYMENT OF SERVICES
Voucher programs have traditionally delivered primary and specialty care services to agricultural workers in geographically dispersed areas. Some homeless and other health center programs also use vouchers to outsource care they cannot provide in-house. This involves contracting with providers outside of the health center. Vouchers authorize a third-party provider to deliver the services, and the voucher goes to the health center for payment. Payment is generally less than the provider's full fee but consistent with other payers, such as Medicaid.
Tables Affected ZIP Code, 3A, 3B, 4
5
6A, 6B, 7
Treatment
Report patients even if the only service they receive is a paid vouchered service if these services would make the patient eligible for inclusion if the health center provided them. A vouchered taxi ride or prescription would not make the individual "countable" because health centers DO NOT count transportation or pharmacy services on Table 5, but a vouchered eye exam would count. Column A: There is no way to account for the time of the voucher providers. As a result, report 0 FTEs for these services. If there is a provider who works at the health center, count the FTE of that provider. For example, count the one-day-a-week family practitioner as 0.20 FTEs on Line 1.
Columns B and B2: Report all visits covered by voucher. DO NOT report visits where the referral is to a provider who is not paid in full for the service (e.g., a "voucher" to a doctor who donates five visits per week or one that pays a portion of the provider's fee with the rest being the patient's responsibility does not generate a visit on Table 5). Diagnoses and Services: The voucher program should receive a bill from the provider, similar to a Health Care Financing Administration (HCFA)-1500, that lists the services and diagnoses. Health centers should track these and report them on Tables 6A, 6B, and 7. Cost of Vouchered Services: Report the costs on the appropriate service line(s). Report medical vouchers on Line 1, not Line 3. Report only those costs paid directly by the health center.
8A
Discounts: Virtually all clinical providers receive less than their full fee. Some health centers report the
amount of these discounts as "donated services." While this is not required, health centers may report the
difference between the voucher provider's full fee and the contracted voucher payment as a donated service
on Line 18, Column C.
Column A, Charges: Report the full charge that providers show on their HCFA-1500 on Line 13 (Self-Pay).
DO NOT use the voucher amount as the full charge.
Column B, Collections: If the patient paid the voucher program or the voucher provider a nominal or other fee, report this in Column B.
9D
Column E, Sliding Fee Discounts: Report the difference between the full charge and the amount that the
patient was supposed to pay in Column E. DO NOT report the full amount in Column E if the patient should
have paid the health center or voucher provider but did not complete payment.
Column F, Bad Debt: Report any amount (such as a nominal fee) that the patient was supposed to pay to the health center but did not. Report bad debts according to the health center's financial policies. DO NOT report amounts that were due but not paid to the referral provider.
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NEW START OR NEW ACCESS POINT (NAP)
Health center service delivery sites may be added in scope of project at any point during the calendar year. NAP grants or designations may be added prior to October 1 during the calendar year. Health centers must submit data for the full calendar year, so health center service delivery sites or NAPs operational prior to the start of the Notice of Award must submit data on all tables with activity covering January 1 to December 31.
Tables Affected ZIP Code, 3A, 3B, 4
6B, 7
Treatment
It is understood that a health center may have never collected some of the data required to be reported in the UDS prior to the start of Notice of Award, such as veteran status, gender identity, member months in managed care, etc. Provide the best data available, but for the first year only, you may have some unusual numbers. Work with your UDS Reviewer to explain apparent data inconsistencies. When it comes to the clinical quality measures, you may need to use a sampling process instead of relying on your PMS or HIT/EHR. See Appendix C for details.
If the added service delivery site or health center will transition to a new HIT/EHR during the calendar year, gather the information for the year across the two systems and analyze them in a separate database to remove any duplication in the data.
RELATIONSHIP BETWEEN PERSONNEL ON TABLE 5 AND COSTS ON TABLE 8A
Personnel classifications should be consistent with cost classifications. The chart below illustrates the relationship between the two tables. The personnel on Table 5 is routinely compared to the costs on Table 8A during the review and analysis process. If there is a reason why such a comparison would look unusual (e.g., volunteers on Table 5 result in no cost on Table 8A or contractor costs on Table 8A with no corresponding FTEs on Table 5), include an explanation on Table 8A. Note that the cost categories on Table 8A are not in the same sequential order as the personnel categories on Table 5.
FTEs Reported on Table 5, Line:
112: Medical Personnel 1314: Medical Lab and X-ray 1618: Dental 20a20c: Mental Health 21: Substance Use Disorder 22: Other Professional 22a22c: Vision 23: Pharmacy 2428: Enabling 24: Case Managers 25: Patient and Community Education Specialists 26: Outreach Workers 27: Transportation Personnel 27a: Eligibility Assistance Workers 27b: Interpretation Personnel 27c: Community Health Workers 28: Other Enabling Services 29a: Other Programs and Services 29b: Quality Improvement Personnel 30a30c and 32: Non-Clinical Support Services 31: Facility Personnel
Have Costs Reported on Table 8A, Line:
1: Medical Personnel 2: Medical Lab and X-ray 5: Dental 6: Mental Health 7: Substance Use Disorder 9: Other Professional 9a: Vision 8a: Pharmacy 11a11h: Enabling 11a: Case Management 11d: Patient and Community Education 11c: Outreach 11b: Transportation 11e: Eligibility Assistance 11f: Interpretation Services 11h: Community Health Workers 11g: Other Enabling Services 12: Other Program-Related Services 12a: Quality Improvement 15: Non-Clinical Support Services 14: Facility
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RELATIONSHIP BETWEEN INSURANCE ON TABLE 4 AND REVENUE ON TABLE 9D
Revenue sources are generally aligned with patient insurance. The chart below illustrates the relationship between the two tables. The insurance on Table 4 is routinely compared to the revenue on Table 9D during the review and analysis process. If there is a reason why such a comparison would look unusual (e.g., large change in insurance coverage), include an explanation on Table 9D.
Principal Third-Party Medical Insurance on Table 4, Line:
Have Revenue Reported on Table 9D, Line:
7: Uninsured--No medical insurance at last visit (includes patients whose service is reimbursed through grant, contract, or indigent care fund)
8a and 8b: Medicaid and Medicaid CHIP (includes Medicaid managed care programs and all forms of state-expanded Medicaid) 9a and 9: Dually eligible and Medicare 10a: Other Public non-CHIP--State and local government insurance that covers primary care
10b: Other Public CHIP (private carrier outside Medicaid) 11: Private--Private (commercial) insurance, including insurance purchased from state or federal exchanges (do not include workers' compensation coverage as health insurance--it is a liability insurance) 13a: Capitated managed care enrollees 13b: Fee-for-service managed care enrollees
13: Self-Pay--Include co-pays and deductibles, state and local indigent care programs (do not include revenues from programs with limited benefits; See Other Public, Lines 79) 13: Medicaid (includes Medicaid expansion)
46: Medicare 79: Other Public--Include patient service revenue from programs with limited benefits, such as family planning (Title X), EPSDT, BCCCP, etc. 79: Other Public 1012: Private--Charges and collections from contracts with private carriers, private schools, private jails, Head Start, and workers' compensation and state and federal exchanges "a" lines "b" lines
RELATIONSHIP BETWEEN PRENATAL CARE ON TABLE 6B AND DELIVERIES ON TABLE 7
The chart below illustrates the relationship and accounting of prenatal care patients and the birth outcomes to be reported on Tables 6B and 7. A "Yes" indicates that the information is to be reported in the specified table and section; a "No" indicates the information is not to be reported. The prenatal care patients on Table 6B are routinely compared to the deliveries and birth outcomes on Table 7 during the review and analysis process. If there is a reason why such a comparison would look unusual, include an explanation on the appropriate table.
Prenatal Care Patient and Birth Outcome Scenarios
Patients still in prenatal care Birth outcomes known Patients known to have delivered, but no birth outcomes Patients who miscarried Still birth outcome Patients lost to follow-up
Table 6B, Lines 1-9 (Age and Trimester of Entry)
Yes Yes Yes
Table 7, Column 1a (Patients who Delivered)
No Yes Yes
Table 7, Columns 1b1d (Birth Outcomes-- report each baby separately) No Yes No
Yes
No
No
Yes
Yes
No
Yes
No
No
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RELATIONSHIP BETWEEN RACE AND ETHNICITY ON TABLES 3B AND 7
The patient population for each clinical quality measure on Table 7 is defined in terms of race and ethnicity, and comparisons are made to the race and ethnicity numbers reported on Table 3B. The following table illustrates the crosswalk between the comparable fields across the two tables.
Race Asian Asian Native Hawaiian Native Hawaiian Other Pacific Islander Other Pacific Islander Black/African American Black/African American American Indian/Alaska Native American Indian/Alaska Native White White More than One Race More than One Race Unreported/Refused to Report Race Unreported/Refused to Report Race
Unreported/Refused to Report Race
Ethnicity Hispanic or Latino/a Non-Hispanic or Latino/a Hispanic or Latino/a Non-Hispanic or Latino/a Hispanic or Latino/a Non-Hispanic or Latino/a Hispanic or Latino/a Non-Hispanic or Latino/a Hispanic or Latino/a Non-Hispanic or Latino/a Hispanic or Latino/a Non-Hispanic or Latino/a Hispanic or Latino/a Non-Hispanic or Latino/a Hispanic or Latino/a Non-Hispanic or Latino/a Unreported/Refused to Report Ethnicity
Table 3B Reference Line 1, Column A Line 1, Column B Line 2a, Column A Line 2a, Column B Line 2b, Column A Line 2b, Column B Line 3, Column A Line 3, Column B Line 4, Column A Line 4, Column B Line 5, Column A Line 5, Column B Line 6, Column A Line 6, Column B Line 7, Column A Line 7, Column B
Line 7, Column C
Table 7 Reference Line 1a Line 2a Line 1b1 Line 2b1 Line 1b2 Line 2b2 Line 1c Line 2c Line 1d Line 2d Line 1e Line 2e Line 1f Line 2f Line 1g Line 2g
Line h
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Appendix C: Sampling Methodology for Manual Patient Health Record Reviews
INTRODUCTION
For each measure discussed on Tables 6B and 7 (except the perinatal measures), health centers have the option of reporting on their entire patient population as a denominator or selecting a scientifically drawn random sample. While this is permitted, as is a reduced denominator containing a minimum of 80 percent of all medical (or dental for the sealants measure) patients from all service delivery sites and grant-funded programs in the defined denominator, full EHR or HIT system reporting is preferred.
Note: Data source must cover the review period (e.g., 5 years for Pap tests, 2 years for immunizations) and include information to assess meeting the numerator criteria with the clinical quality measure, as well as to evaluate exclusions.
If you can meet all conditions, reporting on the denominator--even a reduced denominator--generally provides access to pre-programmed tools, which can facilitate reporting. You may only use a reduced denominator if the factors that required its use are unrelated to the measure variables (see reporting requirements for Tables 6B and 7). This is not a sample, and the methods discussed here are not relevant to these situations.
If the health center cannot report on at least 80 percent of the denominator (or chooses not to use its HIT/EHR), it must use a random sample to report CQMs in the UDS.
RANDOM SAMPLE
A random sample is a part of the denominator where each member of the denominator has the exact same chance of inclusion as every other member.
A true random sample generates outcomes similar to those of the denominator of patients because the sample is representative.
STEP-BY-STEP PROCESS FOR REPORTING CLINICAL QUALITY MEASURES USING A RANDOM SAMPLE
Perform the following steps for each sample. Create a new random sample for each measure.
Step 1: Identify the Patient Population (the Denominator)
Define the denominator for the measure. The denominator must include:
· all active (measurement period) medical patients, · all service delivery sites in the scope of the project, · all funding streams, and · any and all contracted medical services. Identify the number of patients who fit, or who initially appear to fit, the criteria for that measure. Because you will review each patient health record in the sample, you can remove any that was mistakenly included. Create a list and number each member of the patient population in the denominator. The list may be in any sequence because randomization will remove any order bias.
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Step 2: Prepare a Random Sample to the Correct Sample Size
BPHC mandates a sample size of 70. Using one of two recommended sampling methodologies (see below), identify the sample of 70 patient health records.
Step 3: Review the Sample of Patient Health Records to Determine Whether Each Record Has Met the Numerator Criteria for the Clinical Quality Measure
For each clinical quality measure, review available data sources to identify any automated sources to simplify data collection. Because health centers augment the automated data fields (if any) for these sources with text and scanned documents, they DO NOT need to be available for all patients. Examples of data sources include:
· EHRs · disease-specific (PC-DMIS, PECs, i2i-track, etc.) databases · state immunization registries for vaccine histories · logs · PMS For each patient in the sample, determine whether sufficient information is available in these alternative resources to meet the standard. If you cannot meet the standard using the alternative source, review text and scanned information to retrieve required information. For example, consider a patient's health record that shows that they are an active medical patient but does not show the CPT or ICD-10-CM code for a Pap test. Review scanned documents to see if there is a copy of a Pap test done by another agency in the patient's health record.
Step 4: Replace Patients You Exclude from the Sample
Best practices would dictate that the methodology used to select the sample (or the denominator) should be able to test for each required criterion. Some criteria (such as the age of the patient) are easily implemented. Others, such as whether a woman has ever had a hysterectomy, may not be available. When you cannot use criteria to include patients in the denominator, you may use them to exclude patients from a sample. If you determine that a patient health record does not meet the standard criteria, remove the patient health record. If the review is of a sample of patient health records, then select another record to replace the original.
Replace an excluded patient health record with a substitute. Use the replacement methodology described for the sample selected. Any criteria that was missed in selecting a patient health record (e.g., not noting that the woman had a hysterectomy) may be used to exclude a record.
METHODOLOGY FOR OBTAINING A RANDOM SAMPLE
You may use either of the two approved methods for generating a random sample and a sample of replacements for excluded patients:
· Work with a list of random numbers generated for your total patient population. · Select a random starting point and use a calculated interval to find each next member of the sample. Use either method to create a "replacement list" to replace patient health records that were excluded during the review process.
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Option #1: Random Number List
The preferred method for selecting a random sample is to use a random number list. You can create an individualized list of random numbers at the Research Randomizer website. The website requires no password or subscription. To obtain a list of random numbers, complete the questions documented below.
Identifying an Initial List
1. Request one list of 70 numbers.
2. Complete the "Number Range" by entering 1 as the first number and the total number of patients in the denominator for the particular measure under consideration as "n." For example, if there are 628 children who turn 2 years old in the calendar year in the denominator, enter 628 as "n."
3. Click on the button, "Randomize Now!" The site will produce a list of randomly generated numbers. These numbers correspond with the numbered list of patients in the denominator prepared in Step 1 above. It is helpful to ask the website to sort the selected random numbers from lowest to highest.
Identifying a Replacement
To create a sample of patient health records to substitute for excluded records, follow the instructions for creating a list of random numbers for a replacement sample. Rather than selecting 70 numbers for the set, select a smaller sample of 5 to 10 patient health records. In this instance, DO NOT sort the list because doing so will bias the replacement sample toward the lower numbers on the list.
If, upon review, you must exclude a patient health record from the original random sample of 70, replace it with one from the replacement sample. Because of the need to replace ineligible patient health records, you may have to exclude more than 70 records to meet the standard for a particular measure, but the final sample will include 70 records that meet all the selection criteria.
Alternatively, for example, you can draw a sample of 80 patients and use the first 70. If you must replace one, use the 71st, then the 72nd, and so on. In this instance, DO NOT request a sorted list because it will have a bias toward lower numbers.
Input Set of numbers Number per set Number range = 1n Unique numbers Sort numbers
Initial Sample 1 70
Last number in sequence Yes
Yes, least to greatest
Replacements 1
At least 5 or more if needed Last sequence number in list
Yes No
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Option #2: Interval
Identifying an Initial List Sample interval (SI) size equals population size (number in denominator) divided by sample size (70).
The second method uses the same numbered list of records in the denominator created in Step 1 (Identify the Patient Population [the Denominator]). To generate the sample:
1. Calculate the SI by dividing the number of patient health records in the denominator by 70.
2. Randomly pick a patient health record from the first SI. For example, if the SI is 10, the first SI includes patient health records number 1 through number 10. Randomly select one patient health record from this interval to use as your first record.
3. Then, select every nth patient health record where n is the SI until you reach the desired sample size. In our example, if the first patient selected is number 8, and the SI is 10, then the remaining patients to be selected are numbers 18, 28, 38, and so on.
First sequence number plus SI equals second number.
4. Continue through the list until you have identified all 70.
Example Patient Health
Record #
1
2 3 4 5 6 7 8 9 10 11 12 13 14 15
<blank>
Account #
951456
234951 492374 157614 736812 453764 416145 801784 481454 487151 158124 625182 789415 781763 745405
Sample interval (SI) = 3
<blank>
First patient health record = #2
Selected at random between 1 and 3
<blank> <blank> <blank> Next patient health record = #5 (2+3) <blank> <blank> Next patient health record = #8 (5+3) <blank> <blank> Next patient health record = #11 (8+3) <blank> <blank> Next patient health record = #14 (11+3) <blank>
Identifying a Replacement
If a selected patient health record needs to be excluded from the sample, return to the original list and substitute the next record on the list after the excluded record. If the replacement patient health record must be excluded, select the record after that on the list until an eligible record is selected. Resume selection using the next patient health record you had pre-selected for the sample. If you run out of patient health records on the list, continue your count back at the beginning of the denominator. In this manner, more than 70 patient health records may be evaluated for meeting the standard for a particular measure, but 70 records that meet all the selection criteria should be included in the final sample.
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Appendix D: Health Center Health Information Technology
(HIT) Capabilities
INTRODUCTION
The HIT Capabilities Form collects information through a series of questions on the health center's HIT capabilities, including EHR interoperability and eligibility for CMS Promoting Interoperability programs. The HIT Form must be completed and submitted as part of the UDS submission. The form includes questions about the health center's implementation of an EHR, certification of systems, and how widely adopted the system is throughout the health center and its providers.
There are no major changes to this form.
QUESTIONS
The following questions appear in the EHBs. Complete them before you file the UDS Report. Reporting requirements for the HIT questions are on-screen in the EHBs as you complete the form. Respond to each question based on your health center status as of December 31.
1. Does your health center currently have an electronic health record (EHR) system installed and in use, at minimum for medical care, by December 31?
a. Yes, installed at all service delivery sites and used by all providers
· For the purposes of this response, "providers" mean all medical providers, including physicians, nurse practitioners, physician assistants, and certified nurse midwives.
· Although some or all of the dental, mental health, or other providers may also be using the system, as may medical support personnel, this is not required to choose response (a).
· For the purposes of this response, "all service delivery sites" means all permanent service delivery sites where medical providers serve health center medical patients.
· It does not include administrative-only locations, hospitals or nursing homes, mobile vans, or sites used on a seasonal or temporary basis.
· You may check this option if a few newly hired, untrained personnel are the only ones not using the system.
b. Yes, but only installed at
some service delivery sites
or used by some providers
· Select option (b) if one or more permanent service delivery sites did not have the EHR installed or in use (even if this is planned), or if one or more medical providers (as defined on this page under [a]) do not yet use the system.
· When determining if all providers have access to the system, the health center should also consider part-time and locum providers who serve clinic patients.
· Do not select this option if the only medical providers who did not have access were those who were newly hired and still being trained on the system.
c. No
· Select "no" if no EHR was in use on December 31, even if you had the system installed and training had started.
· If the health center purchased an EHR but has not yet put it into use, answer "no."
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This question seeks to determine whether the health center installed an EHR by December 31 and, if so, which product was in use, how broad system access was, and what features were available and in use. DO NOT include PMS or other billing systems, even though they can often produce much of the UDS data.
If a system is in use (i.e., if [a] or [b] has been selected), indicate that it has been certified by the Office of the National Coordinator--Authorized Testing and Certification Bodies.
1a. Is your system certified by the Office of the National Coordinator for Health IT (ONC) Health IT Certification Program? a. Yes b. No Health centers are to indicate the vendor, product name, version number, and ONC-certified health IT product list number. (More information is available at https://chpl.healthit.gov/#/search.) If you have more than one EHR (if, for example, you acquired another practice with its own EHR), report the EHR that will be the successor system or the EHR used for capturing primary medical care.
1a1. Vendor
1a2. Product Name
1a3. Version Number
1a4. ONC-certified Health IT Product List Number
1b. Did you switch to your current EHR from a previous system this year? a. Yes b. No If "yes, but only at some service delivery sites or for some providers" is selected, a box expands for health centers to identify how many service delivery sites have the EHR in use and how many (medical) providers are using it. Please enter the number of service delivery sites (as defined under question 1) where the EHR is in use and the number of providers who use the system (at all service delivery sites). Include part-time and locum medical providers who serve clinic patients. Count a provider who has separate login identities at more than one service delivery site as just one provider.
1c. Do you use more than one EHR or data system across your organization? a. Yes b. No
1c1. If yes, what is the reason? a. Additional EHR/data system(s) are used during transition to primary EHR b. Additional EHR/data system(s) are specific to one service type (e.g., dental, behavioral health) c. Additional EHR/data system(s) are used at specific service delivery sites with no plan to transition d. Other (please describe ______)
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1d. Is your EHR up to date with the latest software and system patches? a. Yes b. No c. Not sure
1e. When do you plan to update/install the latest EHR software and system patches? a. 3 months b. 6 months c. 1 year or more d. Not planned
2. Question removed. 3. Question removed. 4. Which of the following key providers/health care settings does your health center electronically exchange
clinical information with? (Select all that apply.) a. Hospitals/Emergency rooms b. Specialty providers c. Other primary care providers d. Labs or imaging e. Health information exchange (HIE) f. None of the above g. Other (please describe ______) 5. Does your health center engage patients through health IT in any of the following ways? (Select all that apply.) a. Patient portals b. Kiosks c. Secure messaging d. Other (please describe _______) e. No, we DO NOT engage patients using HIT 6. Question removed. 7. How do you collect data for UDS clinical reporting (Tables 6B and 7)? a. We use the EHR to extract automated reports b. We use the EHR but only to access individual patient health records c. We use the EHR in combination with another data analytic system d. We DO NOT use the EHR 8. Question removed. 9. Question removed.
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10. How does your health center utilize HIT and EHR data beyond direct patient care? (Select all that apply.) a. Quality improvement b. Population health management c. Program evaluation d. Research e. Other (please describe ______) f. We DO NOT utilize HIT or EHR data beyond direct patient care
11. Does your health center collect data on individual patients' social risk factors, outside of the data countable in the UDS? a. Yes b. No, but we are in planning stages to collect this information c. No, we are not planning to collect this information
12. Which standardized screener(s) for social risk factors, if any, did you use during the calendar year? (Select all that apply.) a. Accountable Health Communities Screening Tools b. Upstream Risks Screening Tool and Guide c. iHELLP d. Recommend Social and Behavioral Domains for EHRs e. Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) f. Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education (WE CARE) g. WellRx h. Health Leads Screening Toolkit i. Other (please describe __________) j. We DO NOT use a standardized screener
12a. Please provide the total number of patients that screened positive for the following at any point during the calendar year: a. Food insecurity ___________ b. Housing insecurity ___________ c. Financial strain ___________ d. Lack of transportation/access to public transportation ___________
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UDS SUPPORT CENTER, 866-UDS-HELP, UDSHELP330@BPHCDATA.NET 12b. If you DO NOT use a standardized screener to collect this information, please indicate why. (Select all that
apply.) a. Have not considered/unfamiliar with standardized screeners b. Lack of funding for addressing these unmet social needs of patients c. Lack of training for personnel to discuss these issues with patients d. Inability to include with patient intake and clinical workflow e. Not needed f. Other (please describe ___________) 13. Does your health center integrate a statewide Prescription Drug Monitoring Program (PDMP) database into the health information systems, such as health information exchanges, EHRs, and/or pharmacy dispensing software (PDS) to streamline provider access to controlled substance prescriptions? a. Yes b. No c. Not sure
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Appendix E: Other Data Elements
INTRODUCTION
The questions on the Other Data Elements Form collect information on the changing landscape of health centers to include expanded services and delivery systems.
The reporting of COVID-19 vaccines provided to health center patients has been moved from this form to Table 6A.
QUESTIONS
Report on these data elements as part of your UDS submission. Topics include medication-assisted treatment (MAT), telehealth, and outreach and enrollment assistance. Respond to each question based on your health center status as of December 31.
1. Medication-Assisted Treatment (MAT) for Opioid Use Disorder a. How many physicians, certified nurse practitioners, physician assistants, and certified nurse midwives,23 on-site or with whom the health center has contracts, have obtained a Drug Addiction Treatment Act of 2000 (DATA) waiver to treat opioid use disorder with medications specifically approved by the U.S. Food and Drug Administration (FDA) for that indication during the calendar year? b. During the calendar year, how many patients received MAT for opioid use disorder from a physician, certified nurse practitioner, physician assistant, or certified nurse midwife, with a DATA waiver working on behalf of the health center?
2. Did your organization use telemedicine to provide remote (virtual) clinical care services? The term "telehealth" includes "telemedicine" services, but encompasses a broader scope of remote health care services. Telemedicine is specific to remote clinical services, whereas telehealth may include remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services. a. Yes 2a1. Who did you use telemedicine to communicate with? (Select all that apply.) a. Patients at remote locations from your organization (e.g., home telehealth, satellite locations) b. Specialists outside your organization (e.g., specialists at referral centers) 2a2. What telehealth technologies did you use? (Select all that apply.) a. Real-time telehealth (e.g., live videoconferencing) b. Store-and-forward telehealth (e.g., secure e-mail with photos or videos of patient examinations) c. Remote patient monitoring d. Mobile Health (mHealth)
23 With the enactment of the Comprehensive Addiction and Recovery Act of 2016, PL 114-198, opioid treatment prescribing privileges have been extended beyond physicians to include certain qualifying nurse practitioners (NPs), physician assistants (PAs), and certified nurse midwives (CNMs).
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2a3. What primary telemedicine services were used at your organization? (Select all that apply.) a. Primary care b. Oral health c. Behavioral health: Mental health d. Behavioral health: Substance use disorder e. Dermatology f. Chronic conditions g. Disaster management h. Consumer health education i. Provider-to-provider consultation j. Radiology k. Nutrition and dietary counseling l. Other (Please describe ________________)
b. No. If you did not have telemedicine services, please comment on why. (Select all that apply.) a. Have not considered/unfamiliar with telehealth service options b. Policy barriers (Select all that apply.) i. Lack of or limited reimbursement ii. Credentialing, licensing, or privileging iii. Privacy and security iv. Other (Please describe __________________) c. Inadequate broadband/ telecommunication service (Select all that apply.) i. Cost of service ii. Lack of infrastructure iii. Other (Please describe __________________) d. Lack of funding for telehealth equipment e. Lack of training for telehealth services f. Not needed g. Other (Please describe __________________)
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UDS SUPPORT CENTER, 866-UDS-HELP, UDSHELP330@BPHCDATA.NET 3. Provide the number of all assists provided during the past year by all trained assisters (e.g., certified
application counselor or equivalent) working on behalf of the health center (personnel, contracted personnel, or volunteers), regardless of the funding source that is supporting the assisters' activities. Outreach and enrollment assists are defined as customizable education sessions about affordable health insurance coverage options (one-on-one or small group) and any other assistance provided by a health center assister to facilitate enrollment. Enter number of assists _______________ Note: Assists DO NOT count as visits on the UDS tables.
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Appendix F: Workforce
INTRODUCTION
The Workforce Form collects information through a series of questions on health center workforce. It is important to understand the current state of health center workforce training and different staffing models to better support recruitment and retention of health center professionals.
There are no major changes to this form.
QUESTIONS
Report on these data elements as part of your UDS submission. Topics include health professional education/training (DO NOT include continuing education units) and satisfaction surveys. Respond to each question based on your health center status as of December 31.
1. Does your health center provide health professional education/training that is a hands-on, practical, or clinical experience?
a. Yes
b. No
1a. If yes, which category best describes your health center's role in the health professional education/training process? (Select all that apply.) a. Sponsor24 b. Training site partner25
c. Other (please describe ________________)
2. Please indicate the range of health professional education/training offered at your health center and how many individuals you have trained in each category26 within the calendar year.
[blank]
a. Pre-Graduate/Certificate
b. Post-Graduate Training
Medical
1. Physicians a. Family Physicians b. General Practitioners c. Internists d. Obstetrician/Gynecologists e. Pediatricians f. Other Specialty Physicians
2. Nurse Practitioners 3. Physician Assistants 4. Certified Nurse Midwives 5. Registered Nurses 6. Licensed Practical Nurses/ Vocational Nurses
[blank]
[blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration]
[blank]
[blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration]
24 A sponsor hosts a comprehensive health profession education and/or training program, the implementation of which may require partnerships with other entities that deliver focused, time-limited education and/or training (e.g., a teaching health center with a family medicine residency program). 25 A training site partner delivers focused, time-limited education and/or training to learners in support of a comprehensive curriculum hosted by another health profession education provider (e.g., month-long primary care dentistry experience for dental students). 26 Examples of pre-graduate/certificate training include student clinical rotations or externships. A residency, fellowship, or practicum would be examples of post-graduate training. Include non-health-center individuals trained by your health center.
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[blank]
7. Medical Assistants
Dental
8. Dentists 9. Dental Hygienists 10. Dental Therapists 10a. Dental Assistants Mental Health and Substance Use Disorder 11. Psychiatrists 12. Clinical Psychologists 13. Clinical Social Workers 14. Professional Counselors 15. Marriage and Family Therapists 16. Psychiatric Nurse Specialists 17. Mental Health Nurse Practitioners 18. Mental Health Physician Assistants 19. Substance Use Disorder Personnel
Vision
20. Ophthalmologists 21. Optometrists
Other Professionals
22. Chiropractors 23. Dieticians/Nutritionists 24. Pharmacists 25. Other (please describe ________)
a. Pre-Graduate/Certificate [blank for demonstration]
[blank]
[blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration]
[blank]
[blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration]
[blank for demonstration]
[blank]
[blank for demonstration] [blank for demonstration]
[blank]
[blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration]
b. Post-Graduate Training [blank for demonstration]
[blank]
[blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration]
[blank]
[blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration]
[blank for demonstration]
[blank]
[blank for demonstration] [blank for demonstration]
[blank]
[blank for demonstration] [blank for demonstration] [blank for demonstration] [blank for demonstration]
3. Provide the number of health center personnel serving as preceptors at your health center: ____ 4. Provide the number of health center personnel (non-preceptors) supporting ongoing health center training
programs: ____ 5. How often does your health center conduct satisfaction surveys to providers working for the health center?
(Select one.) a. Monthly b. Quarterly c. Annually d. We DO NOT currently conduct provider satisfaction surveys e. Other (please describe _________)
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UDS SUPPORT CENTER, 866-UDS-HELP, UDSHELP330@BPHCDATA.NET 6. How often does your health center conduct satisfaction surveys for general personnel working for the health
center (report provider surveys in question 5 only)? (Select one.) a. Monthly b. Quarterly c. Annually d. We DO NOT currently conduct personnel satisfaction surveys e. Other (please describe _________)
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Appendix G: Health Center Resources
Several resources are available to assist health centers with UDS reporting or EHBs system questions:
Description
UDS reporting questions EHBs account and user access questions EHBs electronic reporting issues
Contact UDS Support Center HRSA Call Center HRSA Call Center
E-mail UDS Support Center or udshelp330@bphcdata.net
HRSA Call Center
HRSA Call Center
Phone
866-837-4357 (866-UDS-HELP)
877-464-4772 Option 3
877-464-4772 Option 1
Other data and resource links, including this manual, a complete set of the UDS tables (note that the table view within EHBs may look different but contains the same fields), notifications of changes to reporting criteria, training opportunities, and other reporting materials and guidance can be found on the BPHC website, UDS Training Website, HRSA Digest, or UDS Modernization Initiative page.
Strategic partnerships, including health center-controlled networks, national cooperative agreements, primary care associations, and primary care offices can be found on the BPHC Quality Improvement website.
Resources are available to assist health centers serving special populations with meeting performance requirements and training needs:
Organization
National Association of Community Health Centers (NACHC)
Website http://www.nachc.org
Contact and E-mail
Margaret Davis mdavis@nachc.com
Phone 301-347-0445
Organization
National Nurse-Led Care Consortium (NNCC)
PHPC Program Website
http://nurseledcare.org/
Contact and E-mail
Kristine Gonnella kgonnella@nncc.us
Phone 215-503-7556
National Center for Health in Public Housing (NCHPH)
Organization Migrant Clinicians Network (MCN)
National Center for Farmworker Health (NCFH)
http://www.nchph.org
Jose Leon info@nchph.org
703-812-8822
MHC Program Website
http://www.migrantclinician.org
Contact and E-mail
Theressa Lyons-Clampitt tlyons@migrantclinician.
org
Phone 512-579-4511
http://www.ncfh.org
Sylvia Partida partida@ncfh.org
512-312-5457
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Organization National Health Care for the Homeless Council (NHCHC)
Corporation for Supportive Housing (CSH)
HCH Program Website http://www.nhchc.org
http://www.csh.org
Contact and E-mail
Dr. Alaina Boyer aboyer@nhchc.org
Colleen Velez colleen.velez@csh.org
Phone 615-226-2292
609-802-5765
Organization
Association of Asian Pacific Community Health Organizations (AAPCHO)
Other Vulnerable Populations
Website
Contact and E-mail
http://www.aapcho.org
Joe Lee joelee@aapcho.org
Phone 510-909-9299
National LGBTQIA+ Health Education Center
Alex Keuroghlian http://www.lgbtqiahealtheducation.org education@fenwayhealth.
org
National Center for MedicalLegal Partnership
http://www.medicallegalpartnership.org
Bethany Hamilton, JD bhamilton1@email.gwu.
edu
Health Information and Technology, Evaluation, and Quality (HITEQ) Center
http://hiteqcenter.org/
hiteqinfo@jsi.com
617-927-6354 202-994-0905 844-305-7440
Organization
National Network for Oral Health Access (NNOHA)
Oral Health
Website http://www.nnoha.org
Contact and E-mail
Phillip Thompson executivedirector@nnoha.
org
Phone 303-957-0635 x6
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UDS PRODUCTION TIMELINE AND REPORT AVAILABILITY
Health centers can access their current year and prior year UDS Reports, as well as several standard reports, through the EHBs web link.
· UDS Preliminary Reporting Environment: OctoberDecember 2021 · UDS annual data collection and reporting: January 1February 15, 2022 · Deadline for submitting a complete UDS Report: February 15, 2022 · UDS reporting freeze: March 31, 2022 · Standard UDS Reports are available in EHBs, as shown below.
o Release of UDS Rollup Reports, Awardee and Look-Alike Profiles, and Awardee Comparison Data Views will be available on the BPHC web pages in August 2022.
o Service area data will be available on the UDS Mapper website in August 2022.
UDS Report Level
Timing
Description
Awardee
LookAlike
Finalized Health Center Tables and XML Data File
Health Center Trend Report
June July/August
Provides health center with data for each of the 11 UDS tables, the HIT, Other Data Elements, and Workforce forms
Compares the health center's performance for key measures (in three categories: Access, Quality of Care/Health Outcomes, and Financial Cost/Viability) with national and state averages over a 3-year period
HC HC, S, N
HC HC, N
UDS Summary Report
UDS Rollup Report
Performance Comparison Report
July/August July/August September
Summarizes and analyzes the health center's current UDS data using measures across various tables of the UDS Report
Compiles annual data reported by health centers and provides summary data for patient characteristics, socioeconomic characteristics, staffing, patient diagnoses and services rendered, quality of care, health outcomes and disparities, financial costs, and revenue
Summarizes and analyzes the health center's latest UDS data, giving details at awardee, state, national, urban, and rural levels with trend comparisons and percentiles
HC, S, N
S, N
Includes all levels
HC, N
N
Includes all levels
Abbreviations indicate geographies and detail level for which each report is available. HC=Health Center, S=State, N=National
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UDS CQMS AND NATIONAL PROGRAMS CROSSWALK
The following table crosswalks the UDS CQMs and other national programs using these measures. Specification details and eCQM flowsheets are available at the eCQI Resource Center. Use the Office of National Coordinator Issue Tracking System to report issues or ask questions about eCQM specifications.
ID
Measure Title
Measure Steward
Table 6B, Line 7 Table 6B, Line 10
Table 6B, Line 11
Table 6B, Line 11a
Table 6B, Line 12
Table 6B, Line 13
Table 6B, Line 14a
Table 6B, Line 17a
Table 6B, Line 18
Early Entry to Prenatal Care
Childhood Immunization Status
Cervical Cancer Screening
Breast Cancer Screening
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Statin Therapy for the Prevention and Treatment of Cardiovascular Disease Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
n/a
National Committee for Quality Assurance National Committee for Quality Assurance National Committee for Quality Assurance
National Committee for Quality Assurance
Centers for Medicare & Medicaid Services
Physician Consortium for Performance Improvement
Centers for Medicare & Medicaid Services
National Committee for Quality Assurance
CMS eCQM
n/a
NQF # n/a
CMS Medicaid Core Set
n/a
Healthy People 2030
MICH-08
MIPS/ QPP
No
CMS117v9
38
Child Core
n/a
Yes
CMS124v9
32
Adult Core
C-09
Yes
CMS125v9 2372 Adult Core
C-05
Yes
CMS155v9
24
Child Core
n/a
Yes
CMS69v9
421e
n/a
n/a
Yes
CMS138v9
28e
Adult Core
n/a
Yes
CMS347v4
n/a
n/a
CMS164v7
(no updated
68
n/a
eCQM)
n/a
Yes
n/a
Yes
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ID
Table 6B, Line 19
Measure Title
Colorectal Cancer Screening
Measure Steward
National Committee for Quality Assurance
CMS eCQM
NQF #
CMS Medicaid Core Set
Healthy People 2030
MIPS/ QPP
CMS130v9
34
n/a
C-07
Yes
Table 6B, HIV Linkage to Line 20 Care
Table 6B, Line 20a
Table 6B, Line 21
HIV Screening
Preventive Care and Screening: Screening for Depression and Follow-Up Plan
n/a
Centers for Disease Control and Prevention
Centers for Medicare & Medicaid Services
n/a CMS349v3 CMS2v10
n/a n/a 418e
n/a
HIV-04
No
n/a
n/a
Yes
Adult Core MHMD-08 Yes
Table 6B, Line 21a
Depression Remission at Twelve Months
Minnesota Community Measurement
CMS159v9 710e
n/a
n/a
Yes
Table 6B, Line 22
Dental Sealants for Children between 69 Years
Dental Quality Alliance American Dental Association
CMS277
(no updated eCQM)27
2508 (claimsbased measure)
Child Core
OH-10
No
Table 7, Section A
Low Birth Weight
Centers for Disease Control and Prevention
n/a
1382
n/a
n/a
No
National
Table 7, Controlling High Committee for
Section B Blood Pressure
Quality
CMS165v9
18
Adult Core HDS-05 Yes
Assurance
Diabetes:
National
Table 7, Hemoglobin A1c Section C (HbA1c) Poor
Committee for Quality
CMS122v9
59
Adult Core
D-03
Yes
Control (>9%)
Assurance
n/a = Not applicable, NQF = National Quality Forum, MIPS = Merit-based Incentive Payment System, QPP = Quality Payment Program
27 Requires a free user login to the USHIK to access measure details.
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Appendix H: Glossary
Accrual basis: Reported when the expense occurs, not when the cash is received.
Adjustment: A discount granted to a third-party payer as part of an agreement between the health center and the payer.
Aged and disabled former migratory agricultural workers: As defined in section 330 (g)(1)(B), individuals who have previously been migratory agricultural workers but who no longer work in agriculture because of age or disability.
Bad debt: Amounts billed to and defaulted by a patient responsible for payment.
Capitation: An agreed-upon amount that a managed care payer pays to the provider (health center) for providing all of the services in an agreed-upon list. The payer/HMO pays the health center a set amount monthly, regardless of whether any services were rendered during the month.
Cash basis: Reported when the cash is received or expended, not when an obligation occurs.
CHIP: The Children's Health Insurance Program (CHIP) Reauthorization Act provides primary health care coverage for children and, on a state-by-state basis, others, especially pregnant patients, mothers, or parents of these children. CHIP coverage can be provided through the state's Medicaid program and/or through contracts with private insurance plans.
Clinical quality measure: A quantifiable indicator used to evaluate how well the health center is achieving standards.
Contracted personnel: People who work under contract at the health center, as opposed to being on salary. They may or may not work regular assigned hours and may or may not receive benefits. They DO NOT have withholding taxes deducted from their paychecks, and they have their income reported to the Internal Revenue Service (IRS) on a 1099 form.
Countable visit: A documented encounter between a patient and a licensed or credentialed provider who exercises their independent professional judgment in the provision of services to the patient. (Virtual visits are allowable for each of the service categories.)
Denominator: As used in clinical quality measure reporting, patients who fit the detailed criteria described for inclusion in the specific measure to be evaluated.
Draw down: A formal request for HRSA to release and transmit to the awardee a portion of money awarded to them in their grant.
Dually eligible: Describes a patient enrolled in both Medicare and Medicaid, with Medicare being the primary insurance.
Electronic health record (EHR)/Electronic medical record (EMR)/Patient health record: A digital record of a patient's status and encounters with a health center, including real-time, patient-centered information available quickly and securely to authorized users.
Exclusions or exceptions: As used in clinical quality measure reporting, patients not to be considered or included in the denominator (exclusions) or removed if identified (exceptions).
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Federal poverty guidelines: An annual statement of the amount of income below which an individual or family of different sizes is considered to be in poverty.
Fee-for-service: Charges that are billed to a third-party payer (or directly to a patient) that list each of the services provided using CPT codes and the charge associated with each of these services, including all-inclusive visit payments and negotiated encounter-based payments.
Fee schedule: A listing of fixed fees for goods or services.
First trimester (prenatal care): Patients who were estimated to be pregnant up through the end of the 13th week after the first day of their last menstrual period.
Full-time equivalent (FTE): One individual who works full-time for the year. Fractions of an FTE are used to identify part-time or part-year individuals, and multiples of an FTE are used to identify multiple individuals.
Full-time personnel: People generally employed 40 hours per week, but subject to organizational definitions. Full-time personnel generally receive benefits, have withholding taxes deducted from their paychecks, and have their income reported to the IRS on a W-2 form. Personnel may or may not have a contract. Personnel are fulltime when they are so defined in their contract and/or when their benefits reflect this status.
Gender identity: An individual's internal sense of their gender as a male, female, a combination of male and female, or another gender. This may or may not align with one's sex assigned at birth.
Gross charges: The full, undiscounted cost of a product or a service.
Hispanic or Latino/a: Describes individuals of specific Spanish or Latino/a heritage, lineage, descent, or country of birth.
Homeless: Describes an individual who lacks housing (without regard to whether the individual is a member of a family), including individuals whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations and individuals who reside in transitional housing. May include children and youth at risk of homelessness, homeless veterans, and veterans at risk of homelessness.
Income: Earnings over a given period of time used to support an individual or household unit based on a set of criteria of inclusions and exclusions. Income is distinguished from assets, as assets are a fixed economic resource, whereas income comprises earnings.
Indigent care programs: State or local programs that pay in whole or in part for services rendered to people who are uninsured. Indigent care programs include 638 compact programs for tribal groups.
Last party rule: Reporting of grant and contract funds based on the entity from which the health center received them, regardless of their original origin.
Locum tenens: People who work at the health center on an as-needed basis during a part-time absence of another provider and when the health center is unable to hire full- or part-time personnel until the position is filled. Locums are uniquely identifiable because they work for an agency and the health center pays the agency rather than the individual. They DO NOT receive benefits from the health center (although they may from the agency they work for) and generally are not covered by the health center's professional liability insurance.
Look-alike: A community-based health care provider that meets the requirements of the HRSA Health Center Program but does not receive Health Center Program section 330 funding.
Managed care: A system in which a premium is paid to an organization that contracts with a health center to provide a range of services to patients assigned to the health center.
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Medicaid: Federal and state-run programs operating under the guidelines of Titles XIX and XXI (as appropriate) of the Social Security Act.
Medicaid expansion: A program that makes Medicaid available to more patients and that requires states to opt in to participate.
Medicare: Federal insurance program for the aged, blind, and disabled (Title XVIII of the Social Security Act).
Member month: One individual enrolled in a managed care plan for one month.
Migratory agricultural workers: For the purposes of health centers receiving a Health Center Program award or designation under section 330(g) of the Public Health Service Act, individuals whose principal employment is in agriculture, who have been so employed within 24 months, and who establish for the purposes of such employment a temporary abode. This includes dependent family members of the individuals described above and individuals who are no longer employed in migratory or seasonal agriculture because of age or disability who are within such a catchment area.
National Health Service Corps (NHSC) assignees: Members of the NHSC assigned by the Corps to a health center. This includes members of the NHSC Loan Repayment Program. These individuals are employees of the U.S. government.
Numerator: As used in clinical quality measure reporting, patient health records (a subset of the denominator) that meet the criteria for the specified measure.
Off-site contract providers: Providers who are contracted for the services who work at a location that is not an in-scope service delivery site as defined in a health center application.
On-call providers: Providers who fill in briefly when someone is absent but may stay for an extended period if the health center is unable to hire full- or part-time personnel for a position. Unlike locums, health centers pay oncall providers directly. They may or may not receive all the usual benefits or a salary and may or may not have payroll and income taxes withheld.
Part-time personnel: People employed by the health center for fewer than 40 hours per week. They receive benefits consistent with their FTE, have withholding taxes deducted from their paychecks, and have their income reported to the IRS on a W-2 form. Part-time personnel may or may not have a contract.
Part-year personnel: Individuals employed or contracted for full or part time for a specific period that may be once or recurring.
Patient: An individual who has at least one countable visit in one or more categories of services: medical, dental, mental health, substance use disorder, vision, other professional, or enabling.
Penalty/paybacks: Payments made by health centers to payers because of overpayments collected earlier or for over-utilization of the inpatient or specialty pool funds in managed care plans.
Prenatal care (first visit): The date a patient has a visit with a physician, NP, PA, or CNM who conducts a prenatal exam to initiate pregnancy-related health care.
Public housing: Public housing agency-developed, -owned, or -assisted low-income housing, including mixed finance projects but excluding housing units with no public housing agency support other than Section 8 housing vouchers.
Race: A physical or social categorization of an individual, presumably based on inheritance.
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Reclassify: Transfer of amounts due from one payer to another payer, including the patient. Reconciliations: Lump-sum retroactive adjustments based on the filing of a cost report. Residents/trainees: Individuals in training for a license or certification who provide services at the health center under the supervision of a more senior individual. Many of these trainees (especially medical and dental residents) already have licenses. Sex: The anatomical and physiological biology of an individual assigned at birth. School-based health center: A health center located on or near school grounds (including pre-school, kindergarten, and primary through secondary schools) that provides comprehensive preventive and primary health services. Seasonal agricultural workers: For the purposes of health centers receiving a Health Center Program award or designation under section 330(g) of the Public Health Service Act, individuals whose principal employment is in agriculture on a seasonal basis and who DO NOT meet the definition of a migratory agricultural worker. Second trimester (prenatal care): Patients who were pregnant and estimated to be between the start of the 14th week and the end of the 27th week after the first day of their last menstrual period. Sexual orientation: How an individual describes their emotional and sexual attraction to others as straight, lesbian or gay, bisexual, or another sexual orientation. Sliding fee discount: A discount applied to the fee schedule that adjusts fees based on the patients' ability to pay based on their income. Straight-line allocation: Allocating non-clinical support services costs based on the proportion of net costs (total costs excluding non-clinical support services and facility cost) that is attributable to (assigned to) each service category. Third trimester (prenatal care): Patients who were estimated to be pregnant for 28 weeks or longer after the first day of their last menstrual period. Veteran: Individuals who served in the active military, naval, or air service, which includes full-time service in the Air Force, Army, Coast Guard, Marines, Navy, Space Force, or as a commissioned officer of the Public Health Service or National Oceanic and Atmospheric Administration. This also includes individuals who served in the National Guard or Reserves on active duty status. Volunteers: Individuals who work at the health center but are not paid for their work. Wraparound payments: An amount equal to the difference between the usual payment and an agreed-upon flat fee, known as an FQHC or PPS rate.
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Appendix I: Acronyms
· AAPCHO: Association of Asian Pacific Community Health Organizations
· ACO: accountable care organization · ADA: American Dental Association · ADHC: adult day health care · AMA: American Medical Association · AMI: acute myocardial infarction · APN: advanced practice nurse · ASCVD: atherosclerotic cardiovascular
disease · AWP: average wholesale price · BCCCP: Breast and Cervical Cancer Control
Program · BDI, BDI-II: Beck Depression Inventory · BDI-PC: Beck Depression Inventory-Primary
Care Version · BHW: Bureau of Health Workforce · BMI: body mass index · BP: blood pressure · BPHC: Bureau of Primary Health Care · CABG: coronary artery bypass graft · CAD-MDD: Computerized Adaptive
Diagnostic Test for Major Depressive Disorder · CARE: Capital Assistance for Hurricane Response and Recovery Efforts · CASA: Clinic Assessment Software Application · CAT-DI: Computerized Adaptive Testing Depression Inventory · CCO: coordinated care organizations · CDC: Centers for Disease Control and Prevention · CEO: chief executive officer · CES-D: Center for Epidemiologic Studies Depression Scale · CFO: chief financial officer · CHC: Community Health Center (program) · CHIP: Children's Health Insurance Program · CIO: chief information officer · CME: continuing medical education · CMO: chief medical officer · CMS: Centers for Medicare & Medicaid Services · CNM: certified nurse midwife · COO: chief operations officer
· COVID-19: coronavirus disease 2019 · CPT: Current Procedural Terminology · CQL: Clinical Quality Language · CQM: clinical quality measure · CSDD: Cornell Scale for Depression in
Dementia · CSH: Corporation for Supportive Housing · CT: computerized tomography · DADS: Duke Anxiety-Depression Scale · DATA: Drug Addiction Treatment Act of
2000 · DEPS: Depression Scale · DGMO: Division of Grants Management
Operations · DNA: deoxyribonucleic acid · DO: doctor of osteopathic medicine · DRE: digital rectal exam · DT, DTaP, DTP: Diphtheria, tetanus,
pertussis · eCQI: Electronic Clinical Quality
Improvement · eCQMs: electronic-specified clinical quality
measures · EHBs: Electronic Handbooks · EHR: electronic health record · EKG: electrocardiogram · EMR: electronic medical records · EMS: emergency medical service · EMT: emergency medical technician · ENDS: electronic nicotine delivery systems · EPSDT: Early and Periodic Screening,
Diagnostic, and Treatment · ESRD: end-stage renal disease · FAQ: frequently asked question · FDA: U.S. Food and Drug Administration · FIT: fecal immunochemical test · FOBT: fecal occult blood test · FPG: federal poverty guidelines · FQHC: federally qualified health center · FTC/TAF: emtricitabine/tenofovir
alafenamide · FTC/TDF: emtricitabine/tenofovir disoproxil
fumarate · FTE: full-time equivalent · GAAP: generally accepted accounting
principles
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· GDS: Geriatric Depression Scale · gFOBT: guaiac fecal occult blood test · HAM-D: Hamilton Rating Scale for
Depression · HbA1c: Hemoglobin A1c · HCFA: Health Care Financing Administration · HCH: Health Care for the Homeless
(program) · HCPCS: Healthcare Common Procedure
Coding System · HEDIS: Healthcare Effectiveness Data and
Information Set · HHS: U.S. Department of Health and Human
Services · HiB: Haemophilus influenza B · HIT: health information technology · HITEQ: Health Information Technology,
Evaluation, and Quality Center · HIV: human immunodeficiency virus · HMO: health maintenance organizations · HPV: human papillomavirus · HR: human resources · HRSA: Health Resources and Services
Administration · HUD: U.S., Department of Housing and
Urban Development · ICD: International Classification of Diseases · iFOBT: immunochemical-based fecal occult
blood test · IHS: Indian Health Service · IPV: inactivated polio vaccine · IRS: Internal Revenue Service · IT: information technology · IVD: Ischemic Vascular Disease · LAL: look-alike · LBW: low birth weight · LCSW: licensed clinical social worker · LDL-C: low-density lipoprotein cholesterol · LGBTQIA+: lesbian, gay, bisexual,
transgender, queer, intersex, asexual, and all sexual and gender minority people · MAT: medication-assisted treatment · MCN: Migrant Clinicians Network · MCO: managed care organization · MD: medical doctor · MFQ: Mood Feeling Questionnaire · MHC: Migrant Health Center (program) · MIPS: Merit-based Incentive Payment System
· MMR: mumps, measles, and rubella · NACHC: National Association of Community
Health Centers · NAICS: North American Industry
Classification System · NAP: New Access Point · NCFH: National Center for Farmworker
Health · NCHPH: National Center for Health in Public
Housing · NCHS: National Center for Health Statistics · NHCHC: National Health Care for the
Homeless Council · NHSC: National Health Service Corps · NNCC: National Nurse-Led Care Consortium · NP: nurse practitioner · NQF: National Quality Forum · OB/GYN: obstetrician/gynecologist · OMB: Office of Management and Budget · OMH: Office of Minority Health · ONC: Office of the National Coordinator for
Health IT · P4P: pay for performance · PA: physician assistant · PACE: Program of All-Inclusive Care for the
Elderly · PAL: Program Assistance Letter · PAP: pharmacy assistance program · PCCM: primary care case management · PC-DMIS: personal computer dimensional
measurement inspection software · PCI: percutaneous coronary intervention · PCMH: patient-centered medical home · PCV: pneumococcal conjugate · PDMP: Prescription Drug Monitoring
Program · PDS: pharmacy dispensing software · PDSA: Plan, Do, Study, Act · PECS: patient electronic care system · PHPC: Public Housing Primary Care
(program) · PHQ: Patient Health Questionnaire
o PHQ-9M: PHQ modified for teens o PHQ-A: PHQ for adolescents · PHS: Public Health Service (Act) · PMPM: per member per month · PMS: Payment Management System (PMS272)
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· PPD: purified protein derivatives · PPS: prospective payment system · PRAPARE: Protocol for Responding to and
Assessing Patients' Assets, Risks, and Experiences · PRE: Preliminary Reporting Environment · PrEP: Pre-Exposure Prophylaxis · PRIME MD: Primary Care Evaluation of Mental Disorders · PSC-17: Pediatric Symptom Checklist · PTSD: post-traumatic stress disorder · QI: quality improvement · QID-SR: Quick Inventory of Depressive Symptomology Self-Report · RBRVU: resource-based relative value unit · RN: registered nurse · RV: rotavirus · SAMHSA: Substance Abuse and Mental Health Services Administration · SARS-CoV-2: strain of severe acute respiratory syndrome-related coronavirus · SBIRT: Screening, Brief Intervention, and Referral to Treatment · SI: sample interval · SNAP: Supplemental Nutrition Assistance Program · SRO: single-room occupancy · SSI: Supplemental Security Income · TAF/FTC: tenofovir alafenamide/emtricitabine · TANF: Temporary Assistance for Needy Families · TDF/FTC: tenofovir disoproxil fumarate/emtricitabine · UCR: usual, customary, and reasonable · UDS: Uniform Data System · USHIK: United States Health Information Knowledgebase · VFC: Vaccines for Children · VSAC: Value Set Authority Center · VZV: pneumococcal conjugate · WE CARE: Well Child Care, Evaluation. Community Resources, Advocacy Referral, Education · WIC: Women, Infants, and Children
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2021 UDS Manual--August 16, 2021 OMB Number: 0915-0193 Expiration Date: 02/28/2023
HRSA Adobe PDF Library 17.11.238