2020 UDS Manual_redline_2 5 2020
2020 UDS Manual_redline_2 5 2020.docx
2020 HRSA Uniform Data System (UDS)
2020 UDS Manual_redline_2 5 2020
OMB: 0915-0193
Bureau of Primary Health Care
Uniform Data System
Reporting Instructions for 2020 Health Center Data
Letter from the Associate Administrator
Dear Health Center Program Participant:
The Health Resources and Services Administration’s (HRSA) Health Center Program has continued to thrive for over 50 years because of your dedication and efforts to deliver primary health care services to underserved and vulnerable populations. More than 28 million people received high-quality, affordable, cost-effective health care from community-based and patient-directed health centers. Over 92 percent of health centers met or exceeded at least one or more Healthy People 2020 goals, and over half (52 percent) of health centers delivered more cost-effective care compared to national benchmarks.
With over 1,400 health centers and over 12,000 delivery sites in the U.S., the District of Columbia, Puerto Rico, the Virgin Islands, and the Pacific Basin, collectively, your work and dedication to the communities you serve reaches far and wide. Health centers are making a significant impact on the nation’s health as you deliver care to our most vulnerable populations, including 1 in 3 families living in poverty, 1 in 5 rural residents, and 1 in 9 children in the country, nearly 1.4 million people experiencing homelessness, 4.5 million patients served at health center sites that are in or immediately accessible to public housing, almost 1 million agricultural workers, and more than 385,000 veterans.
Through new and ongoing investments, an increasing number of health centers are able to deliver comprehensive health care services, including oral health, mental health, and substance use disorder services. Advances in the adoption and utilization of health information technology have increased access through telehealth, promoting the interoperability of health information, and improving the quality of care across the nation.
The data we receive through the Uniform Data System (UDS) is vital to further expand access, address health disparities, improve quality, and reduce the costs of health care. We have updated the 20 20UDS Manual in response to your input at trainings, conferences, and conversations with me and my staff. The Manual aligns with national measures and reporting standards and includes new appendices to capture the changing landscape of health care data collection, as outlined in the Program Assistance Letter 2019-05. The UDS’ clinical quality measures have been revised to align with the Centers for Medicare & Medicaid Services electronic-specified Clinical Quality Measures (eCQMs), capture more detail on depression, HIV, and breast cancer, and this year we will collect information on social determinants of health and Prescription Drug Monitoring Programs.
We continue to modernize the UDS reporting process to increase data standardization across national programs, reduce reporting burden, increase data quality, and expand data use to improve clinical care and operations to benefit you and the patients you serve. Your insights are critical to further advance the Health Center Program, and I encourage you to continue providing feedback.
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
Associate Administrator, Bureau of Primary Health Care
Bureau of Primary Health Care
Uniform Data System Reporting Instructions
For Calendar Year 2020 UDS Data
For help contact: 866-837-4357 (866-UDS-HELP) or udshelp330@bphcdata.net
Health Resources and Services Administration
Bureau of Primary Health Care
5600 Fishers Lane, Rockville, Maryland 20857
2020 Uniform Data System Manual Contents
Tables Shown in Each Report 17
Calendar Year Reporting Period 18
Due Dates and Revisions to Reports 18
How and Where to Submit Data 18
Instructions for Tables that Report Visits, Patients, and Providers 20
Independent Professional Judgment 20
Behavioral Health Group Visits 21
Location of Services Provided 21
Counting Multiple Visits by Category of Service 22
Services and Persons Not Reported on the UDS Report 23
Instructions for ZIP Code Data 26
ZIP Code of Specific Groups 26
10 or Fewer Patients in ZIP Code 27
Instructions for Type of Insurance 27
Table: Patients by ZIP Code 29
Instructions for Tables 3A and 3B 30
Table 3A: Patients by Age and by Sex Assigned at Birth 30
Table 3B: Demographic Characteristics 31
Patients by Hispanic or Latino Ethnicity and Race (Lines 1–8) 31
Hispanic or Latino Ethnicity 31
Patients Best Served in a Language Other than English (Line 12) 32
Patients by Sexual Orientation (Lines 13–19) 32
Patients by Gender Identity (Lines 20–26) 33
Table 3A: Patients by Age and by Sex Assigned at Birth 35
Table 3B: Demographic Characteristics 36
Instructions for Table 4: Selected Patient Characteristics 37
Income as a Percent of Poverty Guideline, Lines 1–6 37
Principal Third-Party Medical Insurance, Lines 7–12 37
Dually Eligible (Medicare and Medicaid) (Line 9a) 39
Other Public Insurance (Non-CHIP) (Line 10a) 39
Other Public Insurance CHIP (Line 10b) 40
Private Insurance (Line 11) 40
Managed Care Utilization, Lines 13a–13c 40
Special Populations, Lines 14–26 41
Total Migratory and Seasonal Agricultural Workers and their Family Members, Lines 14–16 42
Total Homeless Patients, Lines 17–23 43
Total School-Based Health Center Patients, Line 24 44
Table 4: Selected Patient Characteristics 46
Table 4: Selected Patient Characteristics (continued) 47
Instructions for Table 5: Staffing and Utilization 48
Table 5: Staffing and Utilization 48
Staff Full-Time Equivalents (FTEs), Column A 48
Staff by Major Service Category 50
Virtual Visit Considerations 56
Visits purchased from non-staff providers on a fee-for-service basis 56
Do not record visits and patients for services provided by the following: 59
Selected Service Detail Addendum 60
Relationship between Table 5 and Table 8A 61
Table 5: Staffing and Utilization 62
Table 5: Staffing and Utilization (continued) 63
Table 5: Selected Service Detail Addendum 64
Instructions for Table 6A: Selected Diagnoses and Services Rendered 65
Visits and Patients, Columns A and B 65
Visits and Patients by Selected Diagnoses, Lines 1–20d 65
Visits and Patients by Selected Tests/Screenings, Lines 21–26d 66
Visits and Patients by Dental Services, Lines 27–34 67
Services provided by multiple entities: 68
Table 6A: Selected Diagnoses and Services Rendered 69
Table 6A: Selected Diagnoses 69
Table 6A: Selected Services Rendered 71
Instructions for Tables 6B and 7 73
Column A (A, 2A, or 3A): Number of Patients in the Universe (Denominator) 73
Column B (B, 2B, or 3B): Number of Charts/Records Sampled or EHR Total 74
Column C (C or 2C): Number of Charts/Records Meeting the Measurement Standard (Numerator) 75
Column 3F: Number of Charts/Records that Do Not Meet the Measurement Standard (Numerator) 76
Criteria vs. Exceptions and Exclusions in HITs/EHRs vs. Chart Reviews 76
Detailed Instructions for Clinical Measures 76
Instructions for Table 6B: Quality of Care Measures 78
Sections A and B: Demographic Characteristics of Prenatal Care Patients 79
Prenatal Care by Referral Only (check box) 79
Section A: Age of Prenatal Care Patients (Lines 1–6) 79
Section B: Early Entry into Prenatal Care (Lines 7–9), no eCQM 80
Sections C through O: Other Quality of Care Measures 82
Childhood Immunization Status (Line 10), CMS117v8 82
Cervical Cancer Screening (Line 11), CMS124v8 84
Breast Cancer Screening (Line 11a),
CMS125v8 ……………….page TBD
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease (Line 17a), CMS347v3 90
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet (Line 18), CMS164v7 91
Colorectal Cancer Screening (Line 19), CMS130v8 91
HIV Linkage to Care (Line 20), no eCQM 93
HIV Screening (Line 20a), CMS349v2 …………..……page TBD
Preventive Care and Screening: Screening for Depression and Follow-Up Plan (Line 21), CMS2v9 page TBD
Depression Remission at Twelve Months (Line 21a), CMS159v8 ………………………………page TBD
pageDental Sealants for Children between 6-9 Years (Line 22), CMS277v0
HYPERLINK \l "_Toc8636920"
Depression Remission at Twelve Months (Line 21a), CMS159v8 ………………………………page TBD
HIV Screening (Line 20a), CMS349v2 …………..……page TBD
Breast Cancer Screening (Line 11a),
CMS125v8 ……………….page TBD
Table 6B: Quality of Care Measures 97
Instructions for Table 7: Health Outcomes and Disparities 101
Race and Ethnicity Reporting 101
HIV-Positive Pregnant Women, Top Line (Line 0) 102
Deliveries Performed by Health Center Provider (Line 2) 102
Sections B and C: Other Health Outcome and Disparity Measures 104
Controlling High Blood Pressure (Columns 2a-2c), CMS165v8 104
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9 percent) (Columns 3a–3f), CMS122v8 105
Table 7: Health Outcomes and Disparities 107
Instructions for Table 8A: Financial Costs 110
Accrued Costs, Allocated Costs, and Costs after Allocation (Column Definitions) 110
Column B - Allocation of Facility Costs and Non-Clinical Support Service Costs 110
Column C – Total Cost After Allocation of Facility and Non-Clinical Support Services 111
BPHC Major Service Categories (Line Definitions) 112
Medical Care Services (Lines 1–4) 112
Other Clinical Services (Lines 5–10) 113
Enabling, Other Program-Related Services, and Quality Improvement (Lines 11a–13) 115
Facility and Non-Clinical Support Services Costs (Lines 14–16) 116
Total Accrued Cost (Line 17) 117
Value of Donated Facilities, Services, and Supplies (Line 18) 118
Total with Donations (Line 19) 118
Relationship between Table 5 and Table 8A 118
Instructions for Table 9D: Patient-Related Revenue 121
Rows: Payer Categories and Form of Payment 121
State or Local Indigent Care Programs: 123
Column A – Full Charges this Period 124
Column B – Amount Collected This Period 125
Columns C1–C4 – Retroactive Settlements, Receipts, or Paybacks 125
Column E – Sliding Fee Discounts 127
Column F – Bad Debt Write-Off 127
Total Patient-Related Income (Line 14) 128
Table 9D: Patient Related Revenue 129
Instructions for Table 9E: Other Revenue 131
Total Health Center Program (Line 1g) 131
Capital Development Grants (Line 1k) 131
Total BPHC Grants (Line 1) 132
Ryan White Part C – HIV Early Intervention Grants (Line 2) 132
Other Federal Grants (Line 3) 132
Medicare and Medicaid EHR Incentive Grants for Eligible Providers (Line 3a) 133
Total Other Federal Grants (Line 5) 133
Non-Federal Grants or Contracts 133
State Government Grants and Contracts (Line 6) 133
State/Local Indigent Care Programs (Line 6a) 133
Local Government Grants and Contracts (Line 7) 134
Foundation/Private Grants and Contracts (Line 8) 134
Total Non-Federal Grants and Contracts (Line 9) 134
Total Other Revenue (Line 11) 135
Appendix A: Listing of Personnel 137
Appendix B1: Frequently Asked Questions (FAQs) 142
FAQs for ZIP Code by Medical Insurance 142
Appendix B: Special Multi-Table Situations 162
Contracted Care (specialty, dental, mental health, etc.) 163
Services Provided by a Volunteer Provider 163
Women, Infants, and Children (WIC) 164
In-House Pharmacy or Dispensary Services for Health Center Patients 165
In-House Pharmacy for Community (i.e., for non-patients) 166
Contract Pharmacy Dispensing to Clinic Patients, Generally Using 340(b) Purchased Drugs 166
Donated Drugs, Including Vaccines 167
Clinical Dispensing of Drugs 167
Certain Grant-supported Clinical Care Programs: BCCCP, Title X, etc. 168
State or Local Safety Net Programs 169
Tricare, Trigon, Public Employees Insurance, Etc. 169
Issuance of Vouchers for Payment of Services 173
New Start or New Access Point (NAP) 174
Relationship between Staff on Table 5 and Costs on Table 8A 175
Relationship between Race and Ethnicity on Tables 3B and 7 176
Appendix C: Sampling Methodology for Manual Chart Reviews 177
Step-by-step Process for Reporting Clinical Measures Using a Random Sample 177
Step 1: Identify the patient population to be sampled (the universe). 177
Step 2: Prepare the correct sample size. 177
Step 3: Select the random sample. 178
Step 5: Replace patients you exclude from the sample. 178
Methodology for Obtaining a Random Sample 178
Option #1: Random Number List 178
Appendix D: Health Center Health Information Technology (HIT) Capabilities 181
Appendix E: Other Data Elements 185
Appendix G: Health Center Resources 190
UDS Production Timeline and Report Availability 192
UDS CQMs and National Programs Crosswalk 193
PUBLIC BURDEN STATEMENT
The Uniform Data System (UDS) provides consistent information about health centers including patient demographics, 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 reporting 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 OMB control number. The OMB control number for this information collection is 0915-0193 and it is valid until 03/31/2022. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (. paperwork@hrsa.gov HYPERLINK "mailto:paperwork@hrsa.gov" 42 U.S.C. 254b HYPERLINK "http://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section254b&num=0&edition=prelim"
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National Health Service Corps (NHSC)
Definitions of Visits, Patients, and Providers
Services and Persons Not Reported on the UDS Report
Instructions for Tables that Report Visits, Patients, and Providers
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National Quality StrategyCMS electronic Clinical Quality Measures
CMS’ eCQI Resource CenterAppendix GValue Set Authority Center (VSAC)7
Clinical Quality Language (CQL)
CMS117v8
CMS124v8
HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms155v8"
Measure Description
Percentage of patients 3–17 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.
Calculate as follows:
Denominator (Universe) (Columns A and B)
Patients 3 through 17 years of age with at least one outpatient medical visit during the measurement period.
Note: Include children and adolescents who were born on or after January 1, 2002, and on or before December 31, 2015.
Numerator (Column C)
Children and adolescents who have had:
Their BMI percentile (not just BMI or height and weight) recorded during the measurement period and
Counseling for nutrition during the measurement period and
Counseling for physical activity during the measurement period.
Exclusions/Exceptions
Denominator
Patients who have a diagnosis of pregnancy during the measurement period.
Patients who were in hospice care during the measurement period.
Numerator
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 a nurse practitioner.
The UDS numerator differs from the eCQM in that the eCQM requires the numerator elements to be reported separately against two age strata (age 3–11; age 12–17). For UDS purposes, the patients must have had all three numerator components completed in order to meet the measurement standard against one age strata (age 3–17).
Do not count as meeting the performance measure 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), CMS69v8 HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms069v8"
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 when the BMI is outside of normal parameters, a follow-up plan is documented during the visit or during the previous 12 months of that visit
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 (Universe) (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 who were born on or before December 31, 2000, including patients who were 18 years of age or older on the date of their last visit.
Numerator (Column C)
Patients with:
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
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
Patients who are pregnant during the measurement period.
Patients receiving palliative care during or prior to the visit.
Patients who refuse measurement of height and/or weight or refuse follow-up during the visit.
Patients with a documented medical reason during the visit or within 12 months of the visit, including:
Elderly patients (65 years or older) for whom weight reduction/weight 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/mineral deficiency.
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.
Numerator
Not applicable.
Specification Guidance
Report this measure for all patients seen during the reporting period.
An eligible professional or their staff 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. Do not use self-reported values.
BMI may be documented in the medical record at the health center or in outside medical 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 performance has been met.
Document the follow-up plan based on the most recent documented BMI outside of normal parameters.
UDS Reporting Considerations
Documentation in the medical record must show the actual BMI or the template normally viewed by a clinician must display BMI.
Do not count as meeting the measurement standard 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.
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (Line 14a), CMS138v8 HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms138v8"
Measure Description
Percentage of patients aged 18 and older who were screened for tobacco use one or more times within 24 months and who received cessation counseling intervention if identified as a tobacco user.
Calculate as follows:
Denominator (Universe) (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 who were born on or before December 31, 2000.
Numerator (Column C)
Patients who were screened for tobacco use at least once within 24 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
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).
Numerator
Not applicable.
Clinical Guidance
If patients use any type of tobacco (i.e., smokes or uses smokeless tobacco), tobacco cessation intervention (counseling and/or pharmacotherapy) is expected.
If a patient has multiple tobacco use screenings during the 24-month period, use the most recent screening which 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 measurement standard. “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 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 to be evaluated for this measure.
UDS Reporting Considerations
Include in the numerator records that demonstrate that the patient had been asked about their use of all forms of tobacco within 24 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 measurement year.
Include patients who receive tobacco cessation intervention by any provider, including:
Received tobacco use cessation counseling services, or
Received an order for (a prescription or a recommendation to purchase an over-the-counter [OTC] product) a tobacco use cessation medication, or
Are on (using) a tobacco use cessation agent.
Do not count as meeting the measurement standard written self-help materials.
Identify preventive visits using “Preventive Care Services” CPT codes listed 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.
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease (Line 17a), CMS347v3
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 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 (Universe) (Columns A and B)
Patients 21 years of age and older who have an active diagnosis of ASCVD or ever had a fasting or direct laboratory result of LDL-C 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 Type 1 or Type 2 diabetes and with an LDL-C result 70-189 mg/dL recorded as the highest fasting or direct laboratory test result in the measurement year or the 2 years prior; with a medical visit during the measurement period.
Note: Include patients who were born on or before December 31, 1997.
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
Patients who have a diagnosis of pregnancy.
Patients who are breastfeeding.
Patients who have a diagnosis of rhabdomyolysis.
Patients with adverse effect, allergy, or intolerance to statin medication.
Patients who are receiving palliative care.
Patients with active liver disease or hepatic disease or insufficiency.
Patients with end-stage renal disease (ESRD).
For patients 40 through 75 years of age with diabetes who have the most recent fasting or direct LDL-C laboratory test result less than 70 mg/dL and are not taking statin therapy.
Numerator
Not applicable.
Specification Guidance
Current statin therapy use (including statin medication samples provided to patients) must be documented in the patient’s current medication list or ordered during the measurement period.
Do not count other cholesterol lowering medications as meeting the measurement standard—only statin therapy meets the measurement standard.
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), he/she is 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.
UDS Reporting Considerations
Not applicable.
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet (Line 18), CMS164v7
Measure Description
Percentage of patients aged 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 documentation of use of aspirin or another antiplatelet during the measurement period.
Calculate as follows:
Denominator (Universe) (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 year or who had a diagnosis of IVD overlapping the measurement period.
Note: Include patients who were born on or before December 31, 2000.
Numerator (Column C)
Patients who had an active medication of aspirin or another antiplatelet during the measurement period.
Exclusions/Exceptions
Denominator
Patients who had documentation of use of anticoagulant medications overlapping the measurement period.
Patients who were in hospice care during the measurement period.
Numerator
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.
Colorectal Cancer Screening (Line 19), CMS130v8
Measure Description
Percentage of adults 50–75 years of age who had appropriate screening for colorectal cancer.
Calculate as follows:
Denominator (Universe) (Columns A and B)
Patients 50 through 75 years of age with a medical visit during the measurement period.
Note: Include patients born on or after January 1, 1944, and on or before December 31, 1968.
Numerator (Column C)
Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:
Fecal occult blood test (FOBT) during the measurement period.
Fecal immunochemical test (FIT)-deoxyribonucleic acid (DNA) during the measurement period or the 2 years prior to the measurement period.
Flexible sigmoidoscopy during the measurement period or the 4 years prior to the measurement period.
Computerized tomography (CT) colonography during the measurement period or the 4 years prior to the measurement period.
Colonoscopy during the measurement period or the 9 years prior to the measurement period.
Exclusions/Exceptions
Denominator
Patients with a diagnosis or past history of colorectal cancer or total colectomy.
Patients who were in hospice care during the measurement period.
Patients 66 and older who are living long term in an institution for more than 90 days during the measurement period.
Patients 66 and older with advanced illness and frailty because it is unlikely that patients will benefit from the services being measured.
Numerator
Not applicable.
Specification Guidance
Do not count digital rectal exam (DRE), 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).
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 staff and the performing lab/clinician showing the results.
FOBTs can be used to document meeting the measurement standard. This test, if performed, is required each measurement year. For example, a patient who had an FOBT in November 2019 would still need one in 2020.
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.
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 diagnosis.9
Calculate as follows:
Denominator (Universe) (Columns A and B)
Patients first diagnosed with HIV by the health center between October 1 of the prior year through September 30 of the current measurement year 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 ever10 by the health center between October 1, 2019, and September 30, 2020,11 and had at least one medical visit during 2020 or 2019.
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:
Had a medical visit with your health center provider who initiates treatment for HIV, or
Had a visit with a referral resource who initiates treatment for HIV.
Exclusions/Exceptions
Denominator
Not applicable.
Numerator
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 clinician/organization (such as a Ryan White provider), the medical treatment at the referral source must begin and the referral loop must be closed during the 30-day period. Closing the referral loop means the referring provider received documented confirmation that the visit was completed from the provider to whom the patient was referred.
Identification of patients for this measure crosses years and may include prior-year patients.
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:
Were diagnosed elsewhere, even if they can provide documentation of the positive test result.
Had a positive reactive initial screening test but not a positive supplemental test.
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.
Preventive Care and Screening: Screening for Depression and Follow-Up Plan (Line 21), CMS2v9
Measure Description
Percentage of patients aged 12 years and older screened for depression on the date of the visit using an age-appropriate standardized depression screening tool and if positive, a follow-up plan is documented on the date of the positive screen.
This is calculated as follows:
Denominator (Universe) (Columns A and B)
Patients aged 12 years and older with at least one medical visit during the measurement period.
Note: Include patients who were born on or before December 31, 2006.
Numerator (Column C)
Patients who:
Were screened for depression on the date of the visit using an age-appropriate standardized tool and,
If screened positive for depression, a follow-up plan is documented on the date of the positive screen.
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
Patients with an active diagnosis for depression or a diagnosis of bipolar disorder.
Patients:
Who refuse to participate.
Who are in urgent or emergent situations12 where time is of the essence and to delay treatment would jeopardize the patient’s health status.
Whose cognitive capacity, functional capacity or motivation to improve may impact the accuracy of results of standardized assessment tools.
Numerator
Not applicable.
Specification Guidance
The depression screening must be reviewed and addressed in the office of the provider on the date of the visit; the screening must occur on the same date or up to 14 days prior to the date of the visit. Positive pre-screening results indicating a patient is at high risk for self-harm should receive more urgent intervention as determined by the provider.
Standardized depression screening tools are normalized and validated for the age-appropriate patient population in which they are used and must be documented in the medical record.
Use the most recent screening results.
Examples of depression screening tools include, but are not limited to:
Adolescent Screening Tools (12-17 years)
Patient Health Questionnaire for Adolescents (PHQ-A)
Beck Depression Inventory-Primary Care Version (BDI-PC)
Mood Feeling Questionnaire (MFQ)
Center for Epidemiologic Studies Depression Scale (CES-D)
Patient Health Questionnaire (PHQ-9)
Pediatric Symptom Checklist (PSC-17)
Primary Care Evaluation of Mental Disorders (PRIME MD)-PHQ-2
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)
Geriatric Depression Scale (GDS)
Cornell Scale for Depression in Dementia (CSDD)
PRIME MD-PHQ-2
Hamilton Rating Scale for Depression (HAM-D)
Quick Inventory of Depressive Symptomatology Self-Report (QID-SR)
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:
Additional evaluation or assessment for depression.
Suicide risk assessment.
Referral to a practitioner who is qualified to diagnose and treat depression.
Pharmacological interventions.
Other interventions or follow-up for the diagnosis or treatment of depression.
UDS Reporting Considerations
Do not count patients who are re-screened as meeting the measurement standard 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 measurement standard for a follow-up plan to a positive depression screening.
Dental Sealants for Children between 6-9 Years (Line 22), CMS277v0
Measure Description
Percentage of children, age 6–9 years, at moderate to high risk for caries who received a sealant on a first permanent molar during the measurement period.
Calculate as follows:
Denominator (Universe) (Columns A and B)
Children 6 through 9 years of age with an oral assessment or comprehensive or periodic oral evaluation dental visit and are at moderate to high risk for caries in the measurement period.
Note: Include children who were born on or after January 1, 2010, and on or before December 31, 2012.
Numerator (Column C)
Children who received a sealant on a permanent first molar tooth during the measurement period.
Exclusions/Exceptions
Denominator
Children for whom all first permanent molars are non-sealable (i.e., molars are either decayed, filled, currently sealed, or un-erupted/missing).
Numerator
Not applicable.
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 patients through a paid referral.
Use ADA codes to document caries risk level determined through an assessment.
Note: Although draft eCQM reflects age 5 through 9 years of age, use age 6 through 9 as measure steward intended.
Additional information is available to clarify reporting. View FAQs for Table 6B.
Breast Cancer Screening (Line 11a), CMS125v8 HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms125v8"
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
This is calculated as follows:
Denominator (Columns A and B)Universe) (
Women 51-74 years of age with a medical visit during the measurement period
NoteInclude :women who were born on or after January 1, d on or before December 31, 1969.n, a1946
Numerator(Column C)
Women with one or more mammograms during the 27 months prior to the end of the measurement period
Exclusions/Exceptions
Denominator
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.
Patients who were in hospice care during the measurement period.
Patients 66 and older who are living long term in an institution for more than 90 days during the measurement period.
Patients 66 and older with advanced illness and frailty because it is unlikely that patients will benefit from the services being measured.
Numerator
Not Applicable
Specification Guidance
This measure
evaluates primary screening. Do not count biopsies, breast
ultrasounds, or MRIs because they are not appropriate methods for
primary breast cancer screening.
HIV Screening (Line 20a), CMS349v2 HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms349v2"
Measure Description
Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for HIV
This is calculated as follows:
Denominator (Columns A and B)Universe) (
Patients 15 to 65 years of age at the start of the measurement period AND who had at least one outpatient medical visit during the measurement period
Numerator(Column C)
Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday
Note: d on or before December 31, 2004n, a1955 who were born on or after January 1, patientsInclude .
Exclusions/Exceptions
Denominator
Patients diagnosed with HIV prior to the start of the measurement period
Numerator
Not Applicable
Specification Guidance
Provider must have documentation of the administration of the laboratory test present in the patient's medical record.
In cases where the HIV test was performed elsewhere, providers cannot rely on patient attestation or self-report to meet the measure requirements. Providers must request documentation of those test results.
If such documentation is not available, the patient should be considered still eligible for HIV screening.
If such documentation is available, but cannot be provided in a standardized, structured format ( Laboratory Test LOINC code of the test is not known, the entry should use the more generic code LOINC panel code [75622-1HIV be readily incorporated as structured data within the EHR), providers should enter the information into their EHR as a laboratory test in a manner consistent with the EHR in use. If the specific to].
Depression Remission at Twelve Months (Line 21a), CMS159v8 HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms159v8"
Measure Description
The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or 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)Universe) (
Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event. Patients may be screened using PHQ-9 and PHQ-9M up to 7 days prior to the office visit (including the day of the office visit).
Numerator(Column C)
Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older who achieved remission at twelve months as demonstrated by a twelve month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five
Exclusions/Exceptions
Denominator
Patients who died
Patients who received hospice or palliative care services
Patients who were permanent nursing home residents
Patients with a diagnosis of bipolar disorder
Patients with a diagnosis of personality disorder
Patients with a diagnosis of schizophrenia or psychotic disorder
Patients with a diagnosis of pervasive developmental disorder
Numerator
Not Applicable
Specification Guidance
(TBD)
Table 6B: Quality of Care Measures
Reporting Period: January 1, 2020, through December 31, 2020
0 |
Prenatal Care Provided by Referral Only (Check if Yes) |
[blank for demonstration] |
Section – Age Categories for Prenatal Care Patients:
Demographic Characteristics of Prenatal Care Patients
Line |
Age |
Number of Patients (a) |
1 |
Less than 15 years |
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2 |
Ages 15-19 |
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3 |
Ages 20-24 |
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4 |
Ages 25-44 |
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5 |
Ages 45 and over |
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6 |
Total Patients (Sum of Lines 1-5) |
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Section - Early Entry into Prenatal Care
Line |
Early Entry into Prenatal Care |
Women Having First Visit with Health Center (a) |
Women Having First Visit with Another Provider (b) |
7 |
First Trimester |
[blank for demonstration] |
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8 |
Second Trimester |
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9 |
Third Trimester |
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Section - Childhood Immunization Status
Line |
Childhood Immunization Status |
Total Patients with 2nd Birthday (a) |
Number Charts Sampled or EHR Total (b) |
Number of Patients Immunized (c) |
10 |
MEASURE: Percentage of children 2 years of age who received age appropriate vaccines by their 2nd birthday |
[blank for demonstration] |
[blank for demonstration] |
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Section - Cervical and Breast Cancer Screening
Line |
Cervical Cancer Screening |
Total Female Patients Aged 23 through 64 (a) |
Number Charts Sampled or EHR Total (b) |
Number of Patients Tested (c) |
11 |
MEASURE: Percentage of women 23-64 years of age who were screened for cervical cancer |
[blank for demonstration] |
[blank for demonstration] |
[blank for demonstration] |
Line |
Breast Cancer Screening |
Total Female Patients Aged 51 through 74 (a) |
Number Charts Sampled or EHR Total (b) |
Number of Female Patients with one or more mammograms (c) |
11a |
MEASURE: 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 |
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Section E - Weight Assessment and Counseling for Nutrition and Physical Activity of Children and Adolescents
Line |
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents |
Total Patients Aged 3 through 17 (a) |
Number Charts Sampled or EHR Total (b) |
Number of Patients with Counseling and BMI Documented (c) |
12 |
MEASURE: Percentage of patients 3–17 years of age with a BMI percentile and counseling on nutrition and physical activity documented |
[blank for demonstration] |
[blank for demonstration] |
[blank for demonstration] |
Section F – Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Line |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan |
Total Patients Aged 18 and Older (a) |
Number Charts Sampled or EHR Total (b) |
Number of Patients with BMI Charted and Follow-Up Plan Documented as Appropriate (c) |
13 |
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 |
[blank for demonstration] |
[blank for demonstration] |
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Section G – Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Line |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
Total Patients Aged 18 and Older (a) |
Number Charts Sampled or EHR Total (b) |
Number of Patients Assessed for Tobacco Use and Provided Intervention if a Tobacco User (c) |
14a |
MEASURE: Percentage of patients aged 18 years of age and older who (1) were screened for tobacco use one or more times within 24 months, and (2) if identified to be a tobacco user received cessation counseling intervention |
[blank for demonstration] |
[blank for demonstration] |
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Section for the Prevention and Treatment of Cardiovascular Disease TherapyStatin - H
Line |
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease |
Total Patients (a)21 and Older at High Risk of Cardiovascular Events ged A |
Numb(b)er Charts Sampled or EHR Total |
Number of Patients Pres(c)cribed or On Statin Therapy |
17a |
MEASURE: Percentage of patients 21 years of age and older at high risk of cardiovascular events who were prescribed or were on statin therapy |
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Section I - Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
Line |
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet |
Total Patients Aged 18 and Older with IVD Diagnosis or AMI, CABG, or PCI Procedure (a) |
Number Charts Sampled or EHR Total (b) |
Number of Patients with Documentation of Aspirin or Other Antiplatelet Therapy (c) |
18 |
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 |
[blank for demonstration] |
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Section J - Colorectal Cancer Screening
Line |
Colorectal Cancer Screening |
Total Patients Aged 50 through 75 (a) |
Number Charts Sampled or EHR Total (b) |
Number of Patients with Appropriate Screening for Colorectal Cancer(c) |
19 |
MEASURE: Percentage of patients 50 through 75 years of age who had appropriate screening for colorectal cancer |
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Section Measures - HIV LSection \* ALPHABETIC – SEQ
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Revisions to the Standards for the Classification of Federal Data on Race and EthnicityOMB
Instructions for Visits, Patients, and Providers
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Cross-Table Reporting Guidance for Indigent Programs
contract pharmacy reportingAppendix B
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BPHC websiteUDS Training WebsiteUDS Modernization Initiative
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eCQI Resource CenterOffice of National Coordinator Issue Tracking System
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HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms117v8" |
n/a |
Child Core |
n/a |
Yes |
Table 6B, Line 11 |
Cervical Cancer Screening |
National Committee for Quality Assurance |
CMS124v8 HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms124v8" |
n/a |
Adult Core |
C-15 |
Yes |
Table 6B, Line 11a |
Breast Cancer Screening |
National Committee for Quality Assurance |
CMS125v8 HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms125v8" |
n/a |
|
|
|
Table 6B, Line 12 |
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents |
National Committee for Quality Assurance |
CMS155v8 HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms155v8" |
n/a |
Child Core |
n/a |
Yes |
Table 6B, Line 13 |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Plan |
Centers for Medicare and Medicaid Services |
CMS69v8 HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms069v8" |
421e |
n/a |
n/a |
Yes |
Table 6B, Line 14a |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
Physician Consortium for Performance Improvement |
CMS138v8 HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms138v8" |
28e |
Adult Core |
n/a |
Yes |
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Table 6B, Line 17a |
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease |
Centers for Medicare and Medicaid Services |
n/a |
n/a |
n/a |
Yes |
|
Table 6B, Line 18 |
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet |
National Committee for Quality Assurance |
68 |
n/a |
n/a |
Yes |
|
Table 6B, Line 19 |
Colorectal Cancer Screening |
National Committee for Quality Assurance |
CMS130v8 HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms130v8" |
n/a |
n/a |
C-16 |
Yes |
Table 6B, Line 20 |
HIV Linkage to Care |
n/a |
n/a |
n/a |
n/a |
n/a |
No |
Table 6B, Line 20a |
HIV Screening |
Center for Disease Control and Prevention |
CMS349v2 HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms349v2" |
n/a |
|
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|
Table 6B, Line 21 |
Preventive Care and Screening: Screening for Depression and Follow-Up Plan |
Centers for Medicare and Medicaid Services |
CMS2v9 HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms002v9" |
418e |
Adult Core |
n/a |
Yes |
Table 6B, Line 21a |
Depression Remission at Twelve Months |
Minnesota Community Measurement |
CMS159v8 HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms159v8" |
710e |
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Table 6B, Line 22 |
Dental Sealants for Children between 6-9 Years |
Dental Quality Alliance - American Dental Association |
CMS277 (draft) |
2508 (claims-based measure) |
Child Core |
OH-12.2 |
No |
Table 7, Section A |
Low Birth Weight |
Centers for Disease Control and Prevention |
n/a |
1382 |
n/a |
MICH-8.1 |
No |
Table 7, Section B |
Controlling High Blood Pressure |
National Committee for Quality Assurance |
CMS165v8 HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms165v8" |
n/a |
Adult Core |
HDS-12 |
Yes |
Table 7, Section C |
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) |
National Committee for Quality Assurance |
CMS122v8 HYPERLINK "https://ecqi.healthit.gov/ecqm/ep/2020/cms122v8" |
n/a |
Adult Core |
D-5.1 |
Yes |
Notes: n/a = Not applicable, NQF = National Quality Forum, MIPS = Merit-based Incentive Payment System, QPP = Quality Payment Program
Appendix H: Glossary
Accrual basis: Reported when the expense occurs, not when the cash is received.
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.
Allowance: A discount granted to a third-party payer as part of an agreement between the health center and the payer.
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 or CHIP-RA or S-CHIP: The Children’s Health Insurance Program Reauthorization Act (CHIP-RA) provides primary health care coverage for children and, on a state-by-state basis, others, especially pregnant women, 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.
Contract staff: 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.
Dually eligible: Patient enrolled in both Medicare and Medicaid, with Medicare being the primary insurance.
Electronic health record (EHR): A digital record of a patient’s status and interactions with a health center, including real-time, patient-centered information available quickly and securely to authorized users.
Exclusions or exceptions: As used in clinical measure reporting, patients not to be considered or included in the denominator (exclusions) or removed if identified (exceptions).
Federal poverty guidelines: An annual statement of the amount of income below which an individual or family of different sizes are considered to be in poverty.
Fee-for-service: Charges which 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.
Fee schedule: A listing of fixed fees for goods or services.
First trimester (prenatal care): Women who were estimated to be pregnant up through the end of the 13th week after their last menstrual period.
Full-time equivalent (FTE): One person 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 staff: People generally employed 40 hours per week, but subject to organizational definitions. Full-time staff generally receive benefits, have withholding taxes deducted from their paychecks, and have their income reported to the IRS on a W2 form. Staff may or may not have a contract. Staff are full-time when they are so defined in their contract and/or when their benefits reflect this status.
Gender identity: A person’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: Persons of specific Spanish or Latino heritage, lineage, descent, or country of birth.
Homeless: A person 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/household unit based on a set of criteria of inclusions and exclusions. Income is distinguished from assets, as assets are a fixed economic resource while 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 center is unable to hire a full- or part-time staff person until the position is filled. Locums are uniquely identifiable because they work for an agency, and the 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.
Managed care: A system where 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.
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 person 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 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 measure reporting, records (a subset of the denominator) that meet the measurement standard 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 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 center is unable to hire a full- or part-time staff person for a position. Unlike locums, health centers pay on-call providers directly. They may or may not receive all the benefits or a salary and may or may not have payroll and income taxes withheld.
Part-time staff: 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 W2 form. Staff may or may not have a contract.
Part-year staff: Persons employed or contracted for full or part time for a specific period that may be once or recurring.
Patient: A person who has at least one reportable visit in one or more categories of services: medical, dental, mental health, substance use disorder, vision, other professional, and 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.
Performance measure: A quantifiable indicator used to evaluate how well the health center is achieving standards.
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 excludes housing units with no public housing agency support other than Section 8 housing vouchers.
Race: A physical or social categorization of a person, presumably based on inheritance.
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 person. Many of these trainees (especially medical and dental residents) already have licenses.
Sex: The anatomical and physiological biology of a person 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): Women who were pregnant and estimated to be between the start of the 14th week and the end of the 27th week after their last menstrual period.
Sexual orientation: How a person 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 which 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): Women who were estimated to be pregnant for 28 weeks or more weeks after their last menstrual period.
Universe (denominator): As used in clinical measure reporting, patients who fit the detailed criteria described for inclusion in the specific measure to be evaluated.
Veteran: Persons discharged from the uniformed services of the United States.
Visit: A documented contact between a patient and a licensed or credentialed provider who exercises his/her independent, professional judgment in the provision of services to the patient. (Virtual visits are allowable for each of the service categories).
Volunteers: People who work at the health center but not paid for their work.
Wrap-around payments: An amount equal to the difference between the usual payment and an agreed-upon flat fee, known as an FQHC or PPS rate.
9 Note that this measure does not conform to the calendar year reporting requirement.
10 “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.
11 Because the measure allows up to 90 days to complete the follow-up, look back 90 days to find the entire universe of patients who should have had a follow-up during the measurement year.
12 Do not exclude patients seen for routine care in urgent care centers or emergency rooms you operate.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | 2019 UDS Manual |
| Subject | UDS Manual |
| Author | HRSA |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |
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