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Bureau of Primary Health Care

Reporting Instructions for Health Centers

2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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Bureau of Primary Health Care

Uniform Data System Reporting Instructions For use to submit Calendar Year 2015 UDS Data For help contact: 866-837-4357 (866-UDS-HELP) or [emailprotected]

Health Resources and Services Administration Bureau of Primary Health Care 5600 Fishers Lane, Room 16W29, Rockville, Maryland 20857

2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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OMB Control Number 0195-0193 Expiration date 02/28/2018

2015 Uniform Data System Manual Contents Section

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2015 Uniform Data System Manual Contents......................................................................... 3 Introduction .............................................................................................................................11 General Instructions ...............................................................................................................15 Who Submits UDS Reports and the UDS Reporting Period...................................................15 Due Dates and Revisions to Reports .....................................................................................15 How and Where to Submit Data ............................................................................................15 Definitions of Visits, Providers, Patients, and FTEs .............................................................17 Visits .....................................................................................................................................17 Further definitions of visits for different provider types follow..............................................20 Further definitions of interactions not counted as a visit. ....................................................22 Patient ...................................................................................................................................22 Provider .................................................................................................................................23 Full-Time Equivalent Staff......................................................................................................24 Instructions by Table ..............................................................................................................26 Overview of UDS Report .......................................................................................................26 Look-Alike Tables ..................................................................................................................28 The Bureau of Health Workforce (BHW) Primary Care Clinics Tables ...................................28 Instructions for ZIP Code Data ...............................................................................................29 Patients by ZIP Code.............................................................................................................29 Source of Insurance ..............................................................................................................30 Insurance Definitions .........................................................................................................30 Questions and Answers for ZIP Code by Medical Insurance Reporting .................................32 Table Patients by ZIP Code ...................................................................................................33 Instructions for Table 3A and 3B ...........................................................................................34 Table 3A: Patients by Age and Gender..................................................................................34 Table 3B: Patients by Hispanic or Latino Ethnicity / Race / Linguistic Barriers to Care....34 Hispanic/Latino Ethnicity .......................................................................................................34 Race ......................................................................................................................................35 Linguistic Barriers to Care .....................................................................................................36 Questions and Answers for Tables 3A and 3B.......................................................................37 Table 3A: Patients by Age and Gender..................................................................................39 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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Table 3B: Patients by Hispanic or Latino Ethnicity/Race/Linguistic Barriers to Care ..............40 Instructions for Table 4: Selected Patient Characteristics...................................................41 Income as a Percent of Poverty Level, Lines 1-6 ...................................................................41 Principal Third Party Medical Insurance Source, Lines 7-12 ..................................................42 Uninsured (Line 7) .............................................................................................................42 Medicaid (Line 8a, 8b, and 8) .............................................................................................42 S-CHIP or CHIP or CHIP-RA (Line 8b or 10b) ...................................................................43 CHIP-Medicaid (Line 8b) ....................................................................................................43 Medicare (Line 9) ...............................................................................................................43 Dually Eligible Medicare and Medicaid (Line 9a) ................................................................43 Other Public Insurance (Line 10a) ......................................................................................43 Other Public (CHIP) (Line 10b) ..........................................................................................43 Private Insurance (Line 11) ................................................................................................44 Source of Insurance ..............................................................................................................44 Managed Care Utilization, Lines 13a-13c ..............................................................................45 Member Months .................................................................................................................45 Targeted Special Populations, Lines 14-26 ...........................................................................46 Migratory or Seasonal Agricultural Workers and their Family Members, Lines 14–16 ........46 Homeless Patients, Lines 17-23.........................................................................................47 School Based Health Center Patients, Line 24 ...................................................................48 Veterans, Line 25 ...............................................................................................................49 Public Housing, Line 26 .....................................................................................................49 Questions and Answers for Table 4 .......................................................................................50 Table 4: Selected Patient Characteristics ..............................................................................52 Instructions for Table 5: Staffing and Utilization ..................................................................53 Staff Full Time Equivalents (FTEs), Column A .......................................................................53 Staff by Major Service Category.........................................................................................54 Relationship between Table 5 and Table 8A .........................................................................59 Clinic Visits, Column B ..........................................................................................................60 Patients, Column C................................................................................................................60 Questions and Answers for Table 5 .......................................................................................62 Table 5: Staffing and Utilization .............................................................................................65 Instructions for Table 5A: Tenure for Health Center Staff....................................................66 Definitions .............................................................................................................................66 Full and Part Time Staff, Column A .......................................................................................66 Full Time Staff ....................................................................................................................66 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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Part Time Staff ...................................................................................................................66 Part Year Staff ...................................................................................................................66 Contract Staff .....................................................................................................................66 NHSC Assignees ...............................................................................................................67 Loc*ms, On-Call, and Other Service Providers or Consultants Column C .............................67 Locum Tenens ...................................................................................................................67 On-call Providers ...............................................................................................................67 Volunteers..........................................................................................................................67 Residents/Trainees ............................................................................................................67 Off-site Contract Providers .................................................................................................68 Non-Clinical Consultants ....................................................................................................68 Persons (Columns A and C) ..................................................................................................68 Total Months (Columns B and D)...........................................................................................69 Instructions for Columns ........................................................................................................69 Full and Part Time Staff, Column A .......................................................................................69 Loc*ms, On-call, and Other Service Providers and Consultants, Column C ..........................69 Months, Columns B and D .....................................................................................................70 Questions and Answers for Table 5A ....................................................................................71 Table 5A: Tenure for Health Center Staff ...............................................................................72 Instructions for Table 6A: Selected Diagnoses and Services Rendered ............................73 Number of Visits, Column A...................................................................................................75 Lines 1–20d: Visits by Selected Diagnoses ........................................................................75 Lines 21–34: Visits by Selected Tests/Screenings/Preventive and Dental Services ...........75 Number of Patients, Column B ..............................................................................................76 Lines 1–20d: Patients by Diagnosis ...................................................................................76 Lines 21–26d: Patients by Selected Diagnostic Tests/Screening/Preventive Services .......76 Lines 27–34: Patients by Selected Dental Services ...........................................................76 Questions and Answers for Table 6A ....................................................................................78 Table 6A: Selected Diagnoses and Services Rendered.........................................................81 Table 6A: Selected Diagnoses ...........................................................................................81 Table 6A: Selected Services Rendered..............................................................................83 Sources of Codes: .............................................................................................................86 Instructions for Table 6B: Quality of Care Measures ...........................................................87 Sections A and B: Demographic Characteristics of Prenatal Care Patients ...........................88 Section A: Age of Prenatal Care Patients (Lines 1–6) ........................................................88 Section B: Trimester of Entry into Prenatal Care (Lines 7–9) .............................................89 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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Sections C through M: Other Quality of Care Measures ........................................................91 Section C: Childhood Immunization (Line 10) ....................................................................91 Section D: Cervical Cancer Screening (Line 11) ................................................................91 Section E: Weight Assessment and Counseling for Children and Adolescents (Line 12)....91 Section F: Adult Weight Screening and Follow-up (Line 13) ...............................................91 Section G: Tobacco Use Screening and Cessation Intervention (Line 14a)........................92 Section H: Asthma Pharmacologic Therapy (Line 16) ........................................................92 Section I: Coronary Artery Disease (CAD): Lipid Therapy (Line 17) ...................................92 Section J: Ischemic Vascular Disease (IVD): Aspirin or Antithrombotic Therapy (Line 18) 92 Section K: Colorectal Cancer Screening (Line 19) .............................................................92 Section L: HIV Linkage to Care (Line 20) ...........................................................................92 Section M: Patients Screened for Depression and Follow-up (Line 21) ..............................92 Section N: Dental Sealants (Line 22) .................................................................................92 Column Instructions ...............................................................................................................93 Column A: Number of Patients in the “Universe” ................................................................93 Column B: Number of Charts/Records Sampled or EHR Total ...........................................93 Column C: Number of Charts/Records Meeting the Measurement Standard......................94 Defining the Universe: “Criteria” vs. “Exclusions” in EHRs vs. Chart Reviews........................94 Detailed Instructions for Clinical Measures ............................................................................94 Childhood Immunization (Line 10) ......................................................................................95 Cervical Cancer Screening (Line 11)..................................................................................99 Weight Assessment and Counseling for Children and Adolescents (Line 12) ...................101 Adult Weight Screening and Follow-Up (Line 13) .............................................................102 Tobacco Use Screening and Cessation Intervention (Line 14a) .......................................104 Asthma Pharmacologic Therapy (Line 16) .......................................................................105 Coronary Artery Disease (CAD): Lipid Therapy (Line 17) .................................................107 Ischemic Vascular Disease (IVD): Aspirin or Anti-Thrombotic Therapy (Line 18) .............108 Colorectal Cancer Screening (Line 19) ............................................................................110 HIV Linkage to Care (Line 20) ..........................................................................................111 Patients Screened for Depression and Follow-Up (Line 21) .............................................113 Dental Sealants (Line 22).................................................................................................114 Questions and Answers for Table 6B ..................................................................................116 Table 6B: Quality of Care Measures ....................................................................................120 Instructions for Table 7: Health Outcomes and Disparities ...............................................124 HIV Positive Pregnant Women, Top Line (Line 0) ................................................................124 Deliveries Performed by Health Center Provider (Line 2).....................................................124 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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Deliveries and Birth Weight Measure by Race and Hispanic/Latino Ethnicity, Section A (Columns 1a-1d)..................................................................................................................125 Prenatal Care Patients and Referred Prenatal Care Patients Who Delivered During the Year (Column 1a).........................................................................................................................125 Birth Weight of Infants Born to Prenatal Care Patients Who Delivered During the Year (Columns 1b-1d)..................................................................................................................125 Very Low Birth Weight (Column 1b) .................................................................................126 Low Birth Weight (Column 1c)..........................................................................................126 Normal Birth Weight (Column 1d) ....................................................................................126 Race and Ethnicity of Mothers and Infants Born to Prenatal Care Patients Who Delivered During the Year (Lines 1a - i)...............................................................................................126 Hypertension by Race and Hispanic/Latino Ethnicity, Section B (Columns 2a-2c) ...............126 Total Patients Aged 18 to 85 with Hypertension, Column 2a ............................................127 Number of Charts Sampled or EHR Total, Column 2b .....................................................127 Patients with Controlled Blood Pressure, Column 2c .......................................................128 Important Notes about Race and Hispanic/Latino Ethnicity Numbers ...............................128 Diabetes by Race and Hispanic/Latino Ethnicity, Section C (Columns 3a-3f) ......................128 Total Patients Aged 18 to 75 with Type I or II Diabetes, Column 3a .................................129 Number of Charts Sampled or EHR Total, Column 3b .....................................................130 Reported Hemoglobin A1c Levels, Columns 3d1 and 3f ..................................................130 Questions and Answers for Table 7 .....................................................................................132 Table 7: Health Outcomes and Disparities ...........................................................................134 Section A: Deliveries and Birth Weight by Race and Hispanic/Latino Ethnicity .................134 Section B: Hypertension by Race and Hispanic/Latino Ethnicity ......................................135 Section C: Diabetes by Race and Hispanic/Latino Ethnicity .............................................136 Instructions for Table 8A: Financial Costs..........................................................................137 Direct Costs, Allocated Costs, and Costs After Allocation (Column Definitions) ...................137 Column A - Accrued Costs ...............................................................................................137 Column B - Allocation of Facility Costs and Non-Clinical Support Service Costs ..............137 Column C – Total Cost After Allocation of Facility and Non-Clinical Support Services .....138 BPHC Major Service Categories (Line Definitions) ..............................................................139 Medical Care Services (Lines 1-4) ...................................................................................139 Other Clinical Services (Lines 5-10) .................................................................................140 Enabling and Other Program Related Services (Lines 11-13) ..........................................141 Facility and Non-Clinical Support Services Costs (Lines 14-16) .......................................142 Total Accrued Cost (Line 17)............................................................................................143 Value of Donated Facilities, Services, and Supplies (Line 18) ..........................................143 Total with Donations (Line 19)..........................................................................................144 7 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

Conversion from Fiscal to Calendar Year ............................................................................145 Questions and Answers for Table 8A ..................................................................................146 Table 8A: Financial Costs ....................................................................................................147 Instructions for Table 9D: Patient Related Revenue...........................................................148 Rows: Payer Categories and Form of Payment ...................................................................148 Form of Payment .............................................................................................................148 Payer Categories .............................................................................................................148 Columns: Charges, Payments, and Adjustments Related to Services Delivered (Reported on a Cash Basis) ......................................................................................................................150 Column A – Full Charges this Period ...............................................................................150 Column B – Amount Collected This Period ......................................................................151 Columns C1-C4 – Retroactive Settlements, Receipts, or Paybacks .................................151 Column D – Allowances ...................................................................................................152 Column E - Sliding Discounts ...........................................................................................153 Column F - Bad Debt Write Off ........................................................................................153 Other Write Offs ...............................................................................................................154 Total Patient-Related Income (Line 14) ............................................................................154 Questions and Answers for Table 9D ..................................................................................155 Table 9D: Patient Related Revenue (Scope of Project Only) ...............................................157 Instructions for Table 9E: Other Revenue ...........................................................................159 BPHC Grants.......................................................................................................................159 Lines 1a through 1e .........................................................................................................159 Total Health Center Cluster (Line 1g) ...............................................................................159 Capital Improvement Program Grants (Line 1j) ................................................................159 Capital Development Grants (Line 1k) .............................................................................159 Total BPHC Grants (Line 1) .............................................................................................159 Other Federal Grants...........................................................................................................160 Ryan White Part C – HIV Early Intervention Grants (Line 2) ............................................160 Other Federal Grants (Line 3) ..........................................................................................160 Medicare and Medicaid EHR Incentive Grants for Eligible Providers (Line 3a) .................160 Total Other Federal Grants (Line 5) .................................................................................160 Non-Federal Grants or Contracts.........................................................................................161 State Government Grants and Contracts (Line 6) ............................................................161 State/Local Indigent Care Programs (Line 6a) .................................................................161 Local Government Grants and Contracts (Line 7) ............................................................161 Foundation/Private Grants and Contracts (Line 8) ...........................................................162 Total Non-Federal Grants and Contracts (Line 9).............................................................162 8 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

Other Revenue (Line 10)..................................................................................................162 Total Other Revenue (Line 11) .........................................................................................162 Questions and Answers for Table 9E ..................................................................................163 Table 9E: Other Revenues ..................................................................................................164 Appendix A: Listing of Personnel ........................................................................................165 Appendix B: Special Multi-Table Situations ........................................................................169 Contracted Care (Specialty, dental, mental health, etc.) ......................................................169 Services Provided by a Volunteer Provider ..........................................................................170 Interns and Residents..........................................................................................................171 WIC .....................................................................................................................................171 In-house Pharmacy or Dispensary Services for Health Center’s Patients ............................172 In-House Pharmacy for Community (i.e. for non-patients) ...................................................173 Contract Pharmacy Dispensing to Clinic Patients, Generally Using 340(b) Purchased Drugs ............................................................................................................................................174 Donated Drugs, Including Vaccines .....................................................................................175 Clinical Dispensing of Drugs ................................................................................................175 Adult Day Health Care (ADHC) and the Program of All-inclusive Care for the Elderly (PACE) ............................................................................................................................................176 Medi-Medi / Dually Eligible ..................................................................................................176 Certain Grant Supported Clinical Care Programs: BCCCP, Title X, etc. ..............................177 State or Local Safety Net Programs ....................................................................................177 Workers’ Compensation ......................................................................................................178 Tricare, Trigon, Public Employees Insurance, Etc................................................................178 Contract Sites ......................................................................................................................178 CHIP (CHIP-RA) ..................................................................................................................179 Carve-Outs ..........................................................................................................................179 Incarcerated Patients...........................................................................................................180 EHR Staff and Costs ...........................................................................................................181 (Migrant) Vouchers ..............................................................................................................181 Appendix C: Sampling Methodology for Manual Chart Reviews .......................................183 Introduction .........................................................................................................................183 Random Sample ..................................................................................................................183 Step by Step Process for Reporting Clinical Measures Using a Random Sample ................183 Step 1: Identify the patient population to be sampled (the universe).................................183 Step 2: Determine the sample size for manual chart review .............................................184 Step 3: Select the random sample ...................................................................................184

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Step 4: Review the sample of records to determine that each record has met the measurement standard with the clinical measure .............................................................184 Step 5: Replacing patients that should be excluded from the sample ...............................184 Methodology for Obtaining a Random Sample ....................................................................185 Option #1: Random Number List ......................................................................................185 Option #2: Interval............................................................................................................186 Identifying Persistent Asthma Universe Where Codes Are Unavailable ...............................187 Appendix D: Health Center Electronic Health Record (EHR) Capabilities and Quality Recognition ...........................................................................................................................188 Instructions ..........................................................................................................................188 Questions ............................................................................................................................188 Appendix E: Reporting for Health Center Program Look-Alikes .......................................193 Tables and Modifications .....................................................................................................193 Service Area ....................................................................................................................193 Patient Profile ..................................................................................................................193 Staffing and Utilization .....................................................................................................194 Clinical .............................................................................................................................194 Financial ..........................................................................................................................194 Other Forms.....................................................................................................................194 Appendix F: Health Center References ...............................................................................195 PUBLIC BURDEN STATEMENT 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 project is 0915-0193. Public reporting burden for this collection of information is estimated to average 170 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information + 22 hours per individual grant report. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10C-03I, Rockville, Maryland, 20857. DISCLAIMER "This publication lists non-federal resources in order to provide additional information to consumers. The views and content in these resources have not been formally approved by the U.S. Department of Health and Human Services (HHS) or the Health Resources and Services Administration (HRSA). Listing these resources is not an endorsem*nt by HHS or HRSA."

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Introduction This is the 20th edition of the Health Resources and Services Administration’s Bureau of Primary Health Care’s Uniform Data System (UDS) Reporting Instructions for Health Centers. It is designed for use in submitting Calendar Year 2015 UDS Data, and updates all instructions and modifications issued since the first UDS reporting year (1996). This manual supersedes all previous manuals, including instructions provided on the BPHC website prior to December 31, 2015. This manual includes a brief introduction to the Uniform Data System, definitions of terms, instructions for completing each of the tables, and information on the submission of the UDS to the Bureau of Primary Health Care (BPHC) through HRSA’s Electronic Handbook (EHB) system. Detailed table-specific instructions follow and include a set of “Questions and Answers,” addressing issues that are frequently raised when completing the tables. The table-specific instructions highlight any changes to the table that may have been implemented for the current year. Five appendices are included: •

A list of personnel by category and identification of personnel by job title who may be able to produce countable “visits” for the purpose of the UDS

A set of tables which describe how to address specific issues which have impact on multiple tables

Sampling methodologies for selecting patient charts for clinical reviews

Reporting instructions for the form which describes health center’s Electronic Health Record (EHR) system capabilities and Quality Recognition

A summary of the few remaining reporting differences between Section 330-grant supported health centers and look-alikes

The UDS Manual addresses the annual reporting requirements for recipients of the cluster of primary care grants funded by the Health Resources and Services Administration (HRSA) and other health centers designated as look-alikes and certain health centers funded under the Bureau of Health Workforce (BHW). (The authorizing statute is Section 330 of the Public Health Service Act, as amended.) The UDS Report is required of Health Center Program grantees with the following grants and other health centers which have been designated as look-alikes: •

Community Health Center, as defined in Section 330(e) of the Consolidated Health Centers Act as amended

Migrant Health Center, as defined in Section 330(g) of the Act

Health Care for the Homeless, as defined in Section 330(h) of the Act

Public Housing Primary Care, as defined in Section 330(i) of the Act

In addition to the Health Center Program grantees and look-alikes, certain primary care clinics and nurse managed health clinics funded under the HRSA Bureau of Health Workforce (BHW) must also submit a UDS report. The UDS is a core set of information appropriate for reviewing the operation and performance of health centers. The data are collected and reviewed annually to ensure compliance with legislative and regulatory requirements, improve health center performance and operations, and report overall program accomplishments. 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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UDS data help to identify trends over time, enabling HRSA to establish or expand targeted programs and identify effective services and interventions to improve the health of underserved communities and vulnerable populations. These data are compared with national data to review differences between the U.S. population at large and those individuals and families served by health centers for primary care. Much of these data as well as analysis of the data are routinely reported back to health centers through the Electronic Handbook (EHB) and to the public through the Bureau’s website at http://bphc.hrsa.gov/datareporting/index.html. The UDS includes two components, which are submitted by health centers through the EHB: •

The Universal Report, which is completed by all reporting health centers. The Universal report consists of each of the UDS tables, and provides data on patients, services, staffing, and financing across all programs. The data reflect all activities that are considered “in scope” for the reporting agency, and its scope is the same as that which is defined in the health center’s notice of award. The Universal report is the source of unduplicated data on in scope programs.

The Grant Reports, are completed by a sub-set of grantees who receive 330 grants under multiple BPHC Health Center Program funding authorities. Currently, only Section 330 grantees fill out Grant reports. The Grant report consists of one or more additional copies of Tables 3A, 3B, 4, 6A, and part of Table 5. The Grant reports provide comparable data for that portion of the program that falls within the scope of a project funded under a particular funding stream. Separate Grant reports are required for each funding stream when grantees are funded through the Migrant Health Center, Health Care for the Homeless, and Public Housing Primary Care programs unless a grantee is funded under one and only one of these programs. No Grant report is submitted for the scope of activities supported by the Community Health Center Section 330(e) grant since reporting is included in the Universal report.

Health Center Program look-alikes submit a look-alike version of the UDS. It should be noted that BPHC has brought look-alikes into total conformance with the 330-funded UDS Report version, with the exception of a very small number of fields that do not apply to look-alikes. Differences between grantee and look-alike UDS reporting are highlighted in Appendix E and mentioned with each table where there is a difference. A small number of health centers have both Health Center Program grantee sites and look-alike sites, which are required to have separate scopes of project. These “dual status” health centers will complete both grantee and look-alike versions of the UDS, reporting data that represents the scope of project supported by Health Center Program grant funds in the grantee report and the scope of project represented by the look-alike designation in the look-alike report. While Health Center Program grant funds are not permitted to be used to operate sites and services included in the look-alike scope of project, some costs—especially of corporate executives and other non-clinical support staff, their space, etc. —may need to be allocated between the two reports. The look-alike version of the UDS is also found in the Electronic Handbook (EHB). The separate “BHW primary care clinics” version of the UDS is filed by health clinics which receive grants from HRSA under this separate program. The BHW primary care clinic UDS report is aligned with the Health Center Program grantee UDS. A small number of health centers are funded by both the Section 330 Health Center Program and the BHW primary care clinics. They may have overlapping or different scopes of project. These “dual status” health centers will complete both grantee and BHW primary care clinics versions of the UDS, reporting data that represent the scope of project supported by Health Center Program grant funds in the 330 grant report and the scope of project represented by the BHW primary care clinics program 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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in the BHW primary care clinics report. The BHW primary care clinics version of the UDS is also found in the Electronic Handbook. The UDS is comprised of 12 tables designed to yield consistent clinical, operational, and financial data that can be compared with National and State data and trended over time. These tables are: •

Patient Origin: Patients served reported by ZIP code and by primary third party medical insurance source, if any

Table 3A: Patients by age and gender

Table 3B: Patients by race, Hispanic/Latino ethnicity, and language barriers

Table 4: Patients by income (percent of poverty level) and primary third party medical insurance source; Table 4 also reports the number of “special population” patients receiving services, and managed care member months-

Table 5: The annualized full-time equivalent of program staff by position, visits by provider type, and patients by service type

Table 5A: Tenure for selected health center staff

Table 6A: Selected diagnoses for medical, mental health, and substance abuse visits; and selected medical, mental health, substance abuse, vision, and dental services provided

Table 6B: Quality of care measures

Table 7: Health outcomes measures by race and ethnicity

Table 8A: Direct and indirect expenses by cost center

Table 9D: Full charges, collections, and allowances by payer type as well as sliding discounts and patient bad debt

Table 9E: Other, non patient-service income

In addition to these data collection tables, health centers will report on quality recognition and health information technology (HIT) capabilities, including EHR interoperability. This additional form is included in the EHB along with the other tables and must be completed as part of your UDS report submission. The UDS report is always a calendar year report. Agencies whose designation or funding begins, either in whole or in part, after the beginning of the year, or whose designation or funding is terminated, again either in whole or in part, before the end of the year, are still required to report on the entire year. Similarly, agencies with a fiscal year other than 1/1/15 to 12/31/15 will still report on the calendar year, not on their fiscal year. (Organizations designated or funded for the first time during the calendar year and those which were terminated during the year should discuss any issues with calendar year reporting with their assigned UDS Reviewer.) NOTE: In this document, unless otherwise noted, the term “health center” is used to refer to organizations that receive grants under the Health Center Program as authorized under section 330 of the Public Health Service Act, as amended (also referred to as “grantees”), look-like organizations, which are recognized by BPHC as meeting all the Health Center Program requirements but do not receive Health Center Program grants, and primary care clinics funded under the BHW which receive funding through other HRSA funding streams. Some health 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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centers may also be sponsored by tribal or Urban Indian Health Organizations supported by one of the three HRSA programs referenced above.

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General Instructions This section describes submission requirements including who submits UDS reports, when and where to submit UDS data, and how data are submitted.

Who Submits UDS Reports and the UDS Reporting Period

UDS Reports should be submitted directly by the health center via the Electronic Handbooks (EHB). All health centers that were funded or designated in whole or in part before October 1, 2015, are required to report. Health centers must report activity for the entire calendar year, even if they were funded or designated, in whole or in part, for less than the full year, and even if they did not draw down any grant funds during the calendar year. Health centers which are funded or designated for the first time on or after October 1, 2015, are not required to submit a 2015 UDS report and will not have access to the reporting in the EHB. (Note – New Access Points (NAPs) were awarded in May and August of 2015. Therefore, all data related to these new sites must be included in the overall submission.) The following reporting instructions apply to the limited number of “dual status” organizations. (“Dual status” occurs when a health center receives grant funding under section 330 for sites in the grant’s approved scope of project and, at the same time, operates at least one other site under a look-alike designation.) Health centers which had a look-alike designation only prior to October and one or more look-alike site(s) received NAP funding: Exclude the data related to the NAP site(s) from the look-alike UDS report for 2015 AND report the data related to the NAP site(s) in the grantee UDS report for 2015. Under extenuating circ*mstances (e.g., the physical destruction of the health center) exemptions may be granted. Health centers must request such exemptions directly from the BPHC Office of Quality Improvement.

Due Dates and Revisions to Reports

UDS Reports may be submitted after January 1, 2016 and are due February 15, 2016. Between February 15 and March 31, health centers work with their UDS Reviewer to identify and correct potential data errors. Final corrected submissions are due by March 31, and changes after this date are not accepted. To request assistance at any time, please contact the UDS Support Center at 1-866-UDS-HELP.

How and Where to Submit Data

Uniform Data System (UDS) data are reported through an on-line process, using a web-based data collection system that is a part of the HRSA Electronic Handbooks (EHBs). Health center staff will utilize their EHB user name and password to log into the EHB at https://grants3.hrsa.gov/2010/WebEPSExternal/Interface/common/accesscontrol/login.aspx to complete and submit their UDS Report. Users are able to submit the UDS Report using standard Web browsers 1 through a Section 508-compliant user interface. The system provides users with electronic forms that will guide them in completing their reports.

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While most browsers should work with the EHB, it is certified to work with Internet Explorer (IE) Version 8.0 through 10.0 or Firefox 3.6 or higher. Health centers having a problem with other browsers should consider using IE-8, 9, or109 or Firefox 3.6 for this task. As a rule, IE-11 will also work, though it may result in a false error saying that the user is using an earlier version. More information about EHB’s Recommended Settings are available at https://grants.hrsa.gov/2010/WebEPSExternal/Interface/Common/BrowserSettingsExt.aspx?IsPopUp=false.

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Users can work on the forms in sections, saving interim or partial versions online as they work, and return to complete them later, as necessary. Work is saved in the EHB, but not considered “filed” until the responsible party at the health center takes this final action. This may be the CEO of the organization or the authority may be delegated to another party; however, submission carries with it the acknowledgement that the responsible party in the health center has reviewed and approved the data. Incomplete reports cannot be filed. Health centers may distribute the data entry responsibilities to multiple users, each using his/her own login and password. However, one individual must be designated as the UDS Contact (their name is entered into a field in the report) and this person should be able to explain all of the tables during the review process. Note that health center staff may be assigned either “view” or “edit” privileges, however these privileges are for the entire UDS, not just specific tables. Automated edits will check for inconsistent or questionable quantitative and qualitative data to ensure accuracy. The EHB will provide users with a summary of which tables are complete as well as a list of audit questions which must be reviewed. Note that the audit questions are general and may not apply to some health centers unique circ*mstances. Data audit findings must be corrected or if the submitter thinks there is no error in the data reported, the accuracy of the data must be clearly explained, including detail about the unique circ*mstances.

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Definitions of Visits, Providers, Patients, and FTEs This section provides definitions which are critical for consistent reporting of UDS data across health centers. Most definitions have been in use for years or decades and permit comparisons with data from prior years, as well as comparisons across groups of submitting health centers or the U.S. population at large.

Visits

“Visits” are used both to determine who is counted as a patient (Tables 3A, 3B, 4, 5, 6A, 6B, and 7) and to report visits by type of provider staff (Table 5) and visits where selected diagnoses were made or where selected services were provided (Table 6A). To be counted as having met the visit criteria, the interaction must be: •

Documented,

Face-to-face contact between a patient and a

Licensed or otherwise credentialed provider, who

Exercises independent, professional judgment in the provision of services to the patient.

To be included as a visit, services rendered must be documented in a chart in the possession of the health center. (In the case where a clinic provider is documenting in a hospital or nursing home record, a discharge summary, which separately documents the details of the interactions from an outside institution, included in the health center medical records, is acceptable.) Not all health center staff may provide countable visits. Appendix A provides a list of health center personnel and the usual status of each as a provider or non-provider for purposes of UDS reporting. Note, however, that providers do many things, including interacting with patients, which do not meet the visit criteria. Visits, which are provided by contractors and paid for by the health center, including Migrant Voucher visits or out-patient or in-patient specialty care associated with an at-risk managed care contract, are considered to be visits to be counted on the UDS to the extent that they meet all other criteria. In these instances, if the visit is not documented in the patient’s medical record, a summary of the visit (rather than the complete record) must appear in the patient’s medical record, including all appropriate CPT and ICD-9/ICD-10 codes in order to ensure that the EHR can be used by the health center for reporting the UDS. NOTE: This year marks the transition from ICD-9 to ICD-10 codes. This manual includes the necessary codes for reporting using data drawn from both ICD-9 and ICD-10 codes. Careful attention is required to ensure reported patient activity is unduplicated. Additional information is available on the conversion process at the Centers for Medicare and Medicaid Services. Many activities carried out by health centers, with both patients and non-patients, are not included in this definition and are not reported on the UDS report. Many of these are critical to the care of the patient and/or the health of the community and are not unimportant. Rather, they are activities which BPHC has chosen not to include in the detailed health center reports. Further elaboration of the definitions and criteria for defining and reporting visits, along with additional limits, are included below. Table 5 provides further clarifications to these definitions. See page 59. 1. To meet the criterion for independent professional judgment, the provider must be acting on his/her own when serving the patient and not assisting another provider. For example, a nurse assisting a physician during a physical examination by taking vital 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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signs, recording a history or drawing a blood sample is not credited with a separate visit. Independent judgment implies the use of the professional skills gained through formal training and experience associated with the profession of the individual being credited with the visit and unique to that provider or other similarly or more intensively trained providers. Eligible medical visits usually involve one of the “Evaluation and Management” billing codes (99201–05 or 99211–15) or one of the health maintenance codes (99381-87, 99391-97) 2. 2. To meet the criterion for documentation, the service (and associated patient information) must be recorded in written or electronic form in a system which permits ready retrieval of current data for the patient. The patient record does not have to be a complete health record in order to meet this criterion. For example, if an individual receives services on an emergency basis and these services are documented, the documentation criterion is met even though some portions of the health record may not be complete. Providers who see their (existing, previously registered) patients at a hospital or nursing home and make a note in the institutional file can satisfy this criterion by including a summary note upon discharge indicating activities for each of the dates for which a visit is claimed. Screenings such as those frequently conducted at health fairs or at schools, immunization drives for children or the elderly, services provided enmass to identified groups, such as dental varnishes or sealants provided at schools, and similar public health efforts are not counted as visits regardless of the level of documentation. 3. Group activities: When a behavioral health provider (i.e., a mental health or substance abuse provider) renders services to several patients simultaneously, the provider can be credited with a visit for each person only if the provision of service is noted in each person’s health record. Such visits are limited to behavioral health services. Examples of such non-medical "group visits" include family therapy or counseling sessions, and group mental health counseling during which several people receive services and the services are noted in each person’s health record. In such situations, each patient is normally billed for the service. If only one person is billed (for example, where a relative participates in a counseling session for a patient) only the patient who is billed is counted as a patient and only that patient’s visit is counted. In addition, when a behavioral health provider conducts services via telemedicine/telehealth, the provider can be credited with a visit only if the service is noted in the patient’s record. The session will normally be billed to the patient or a third party. Medical visits must be provided on an individual basis in order to be counted in the UDS. Other categories of telemedicine, patient education or health education classes (e.g., diabetics learning about diet control) are not credited as visits. 4. Location: A visit may take place in the health center or at any other approved site or location in which project-supported activities are carried out. Examples of other sites and locations which may be approved include mobile vans, hospitals, patients’ homes, schools, nursing homes, homeless shelters, and extended care facilities. (If visits at these sites occur on a regularly scheduled basis the site must be an approved site within the scope of the agency’s grant.) Visits also include contacts with existing patients who are hospitalized, where health center medical staff member(s) follow the patient during the hospital stay as physician of record or where they provide consultation to the

2

As described in the Current Procedural Terminology, (CPT) 2014. American Medical Association

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physician of record provided they are being paid by the health center for these services and the patient is billed either for the specific service or through a global fee. A reporting entity may not count more than one inpatient visit per patient per day regardless of how many clinic providers see the patient or how often they do so. When a patient is first encountered in a hospital or nursing home or a similar facility, which is not specifically approved as a service delivery site by BPHC, none of the services for that patient are reported on the UDS. 5. Ancillary services including, but not limited to, drawing blood, collecting urine specimens, performing laboratory tests (including pregnancy tests and PPDs), taking Xrays, giving immunizations or other injections, and filling/dispensing prescriptions, including prescriptions for substance abuse prevention or treatment, do not constitute visits, regardless of the level or quantity of supportive services. 6. Under certain circ*mstances a patient may have more than one visit with the health center in a day. The number of visits per service delivery location per day is limited as follows. On any given day a patient may have, at a maximum: o

One medical visit (physician, nurse practitioner, physician assistant, certified nurse midwife, or nurse)

o

One dental visit (dentist or hygienist)

o

One other professional health visit for each type of other professional health provider (nutritionist, podiatrist, speech therapist, acupuncturist, etc.)

o

One vision services visit (ophthalmologist, optometrist)

o

One enabling service visit for each type of enabling provider (case management or health education)

o

One mental health visit

o

One substance abuse visit

If multiple medical providers deliver multiple services on a single day (e.g., an Ob-Gyn provides prenatal care and an Internist treats hypertension) only one of these visits may be counted on the UDS. While some third party payers may recognize these as billable, only one of them is countable. The decision as to which provider gets credit for the visit on the UDS is up to the health center. Internally, the health center may follow any protocol it wishes in terms of crediting providers with work performed. An exception to this rule, designed to address the operational structure of homeless and agricultural worker programs, allows medical services provided by two different medical providers located at two different sites to be counted on the same day. This permits patients who are seen in clinically problematic environments (e.g., in parks or migrant camps), by non-physician providers, to be seen later in the same day at the health center’s fixed clinic site by a different, generally higher level, provider. 7. Any given provider may be credited with no more than one visit with a given patient in a single day, regardless of the types or number of services provided or where they are provided. 8. The visit criteria are not met in the following circ*mstances: o

When a provider participates in a community meeting or group session that is not designed to provide clinical services; examples of such activities include information sessions for prospective patients, health presentations to community

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groups (high school classes, parent teacher association (PTA), etc.), and information presentations about available health services at the center. o

When the only health service provided is part of a large-scale effort, such as a mass immunization program, screening program, or community-wide service program (e.g., a health fair or en-mass application of dental varnishes)

o

When a provider is primarily conducting outreach and/or group education sessions, not providing direct services

o

When the only services provided are lab tests, x-rays, sonography, mammography, retinography, immunizations or other injections, TB tests or readings, and/or prescription refills

o

When narcotic agonists or antagonists or mixes of these are dispensed to a patient on a regular basis such as daily or weekly

o

Services performed under the auspices of a women, infants, and children (WIC) program or a WIC contract

Further definitions of visits for different provider types follow. • Physician Visit: A visit between a physician (including a licensed resident) and a patient •

Nurse Practitioner (NP) Visit: A visit between a nurse practitioner and a patient in which the practitioner acts as an independent provider

Physician Assistant (PA) Visit: A visit between a physician assistant and a patient in which the practitioner acts as an independent provider

Certified Nurse Midwife (CNM) Visit: A visit between a certified nurse midwife and a patient in which the practitioner acts as an independent provider

Nurse Visit (Medical): A visit between an RN, LVN, or LPN and a patient in which the nurse acts as an independent provider of medical services exercising independent judgment. Services which meet these criteria 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 contact with the patient during the visit, but must still meet the requirement of exercising independent professional judgment. This would include nurses who provide triage services, and visiting nurses who see patients on their own in the patients’ homes and evaluate their condition. In order to be counted, the visits must be charged for and are generally coded as 99211 visits 3. Administration or dispensing of drugs, giving vaccinations or DepoProvera or other shots, wound care, taking health histories, and making referrals for or following up on external referrals are never counted as visits on the UDS. Nurses may not have a countable visit with a person who is not a registered patient of the health center. (Note that most States prohibit an LVN or an LPN from exercising independent judgment, in which case no visits would be counted for them. Note also that under no circ*mstances are services provided by medical assistants or other non-nursing personnel counted as nursing visits.)

Dental Services Visit: A visit between a dentist or dental hygienist and a patient for the purpose of prevention, assessment, or treatment of a dental problem, including

3

As described in the Current Procedural Terminology, (CPT) 2014. American Medical Association

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restoration; NOTE: A dental hygienist is credited with a visit only when s/he provides a service independently, not jointly with a dentist. Two visits may not be generated during a patient’s visit to the dental clinic in one day, regardless of the number of clinicians who provide independent services or the volume of service (number of procedures) provided. The application of dental varnishes, fluoride treatments, and dental screenings, especially in a group setting, or absent other comprehensive dental services, does not qualify as a visit. Under no circ*mstances may the services of students or anyone else other than a licensed dental provider be credited with dental visits, even if these individuals are working under the supervision of a licensed dental provider. Dental therapists, although licensed in some states, are not counted as dental providers for purposes of the UDS even though their services are billed and paid for. (They may be counted under the “other professional health” category.) Physicians and other medical providers who examine a patient’s dentition or provide fluoride treatments are not credited with a dental visit. •

Mental Health Visit: A visit between a licensed mental health provider (psychiatrist, psychologist, LCSW, and certain other masters prepared mental health providers licensed by specific States) or an unlicensed mental health provider credentialed by the center, and a patient, during which mental health services (i.e., services of a psychiatric, psychological, psychosocial, or crisis intervention nature) are provided. (NOTE: The term “behavioral health” is synonymous with the prevention or treatment of mental health and substance abuse disorders. All visits, providers, and costs classified by a health centers as “behavioral health” visits must be parsed out into mental health or substance abuse.)

Substance Abuse Visit: A visit between a substance abuse provider (e.g., a mental health provider, credentialed substance abuse counselor, or rehabilitation therapist) and a patient, during which alcohol, or drug abuse services (i.e., assessment and diagnosis, treatment, or aftercare) are provided; programs which include the regular use of narcotic agonists or antagonists or other medications on a regular (daily, every three days, weekly, etc.) basis are to count the counseling services as visits but not the dispensing of the drugs, regardless of the level of oversight that occurs during that activity. NOTE: The term “behavioral health” is synonymous with the prevention or treatment of mental health and substance abuse disorders. All visits, providers, and costs classified by a health center as “behavioral health” visits must be parsed out into mental health or substance abuse.

Vision Services Visit: A visit between a vision service provider and a patient during which eye exams are performed by an ophthalmologist or an optometrist for the purpose of early detection, care, treatment, and prevention for those with eye disease or chronic diseases such as diabetes, hypertension, thyroid disease, and arthritis, or for the prescription of corrective lenses. These exams also provide opportunities to promote behavioral changes linked to eye health (e.g., smoking, excessive use of alcohol). Under no circ*mstances may the services of students or anyone other than a licensed vision services provider be credited with vision services visits. Retinography, whether performed by a licensed vision services provider or anyone else, is not considered a vision visit absent a more comprehensive vision exam by a vision service provider.

Other Professional Visit: A visit with a health provider, besides those listed and described in this section of the manual, and a patient during which other forms of health services are provided. An extensive, but potentially not all-inclusive, list of other professionals is provided in Appendix A. These professionals are usually, but not

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always, licensed by some entity. They are generally credentialed and privileged by the health center’s governing Board. •

Case Management Visit: A visit between a case management provider and a patient during which services are provided that assist patients in the management of their health and social needs, including patient needs assessments, the establishment of service plans, and the maintenance of referral, tracking, and follow-up systems; these must be face to face with the patient. Third party interactions on behalf of a patient are not counted as case management visits. When a case manager serves an entire family (e.g. in assisting in housing or Medicaid eligibility) only one visit is generated, generally for an adult member of the family, regardless of documentation in other charts. As a rule, case management services are provided to support the delivery of other health care services as described above and are not the only types of services provided to a patient.

Health Education Visit: A one-on-one visit between a health education provider and a patient in which the services rendered are of an educational nature relating to health matters and appropriate use of health services (e.g., family planning, HIV, nutrition, parenting, or specific diseases such as diabetes or hypertension). As a rule, health education services are provided to support the delivery of other health care services, as described above and are not the only types of services provided to a patient. Participants in health education classes or other group activities are not considered to have had visits.

Further definitions of interactions not counted as a visit. • Tests: Tests are provided to support the services of the clinical programs. Neither laboratory tests (including PPDs, pregnancy tests, HbA1c tests, blood pressure tests, etc.) nor imaging tests (including sonography, radiology, mammography, retinography, computerized axial tomography scans, and other imaging) are counted as a visit by themselves. •

Dispensing Medications: Dispensing medications is not considered a visit. This includes dispensing medications from a pharmacy (whether by a Clinical Pharmacologist or a Pharmacist), giving any injection (including vaccines and family planning methods regardless of education provided at the same time), or providing narcotic agonists or antagonists or mixes of these (regardless of whether or not the patient is assessed at the time of the dispensing).

Patient Patients are individuals who have at least one reportable visit during the reporting year, as defined above. The term “patient” is not limited to recipients of medical or dental services; the term is used universally to describe all persons who receive UDS-countable visits. The Universal report includes all patients who have at least one visit during the year which is within the scope of activities supported by any of the grants and programs covered by the UDS. These visits are reported on Table 5. On the ZIP Code Table, Tables 3A and 3B, and in each section of Tables 4 and 6A of the Universal report, each patient may be counted once and only once, even if s/he received more than one type of service (e.g., medical, dental, enabling) or received services supported by more than one BPHC grant. For each Grant report, patients reported are those who have at least one visit during the year within the scope of project activities supported by the specific BPHC grant. A patient counted in any cell on a Grant report is also included in the same cell on the Universal report. For this 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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reason, the number in any cell of a Grant report will never be greater than the number in the comparable cell of the Universal report. Persons who only receive services from community based efforts such as immunization programs, medical or dental screening programs, dental varnishing programs, and health fairs are not counted as patients. Persons whose only service from the health center is a part of the WIC program or other programs are not counted as patients. During the course of addressing the health care needs of the community, health centers see many individuals who do not become patients as defined by and counted in the UDS process. “Patients,” as defined for the UDS, never include individuals who have such limited contacts with the health center, whether or not documentation is done on an individual basis. Table 5 provides further clarifications to these definitions. See page 59. These other service users include, but are not limited to, persons whose only contact is: •

When a provider participates in a community meeting or group session that is not designed to provide clinical services; examples of such activities include information sessions for prospective patients, health presentations to community groups (high school classes, PTA, etc.), and information presentations about available health services at the center.

When the only health service provided is part of a large-scale effort, such as an immunization program, medical or dental screening program, dental varnishing program, dental fluoride application program, or community-wide service program (e.g., a health fair)

When a provider is primarily conducting outreach and/or group education sessions, not providing direct services

When the only services provided are lab tests, x-rays, sonography, mammography, retinography, immunizations or other injections, TB tests or readings, and/or filling or refilling a prescription

When narcotic agonists or antagonists or mixes of these are dispensed to a patient on a regular basis such as daily or weekly

Services performed under the auspices of a WIC program or a WIC contract

Provider

A provider is the individual who assumes primary responsibility for assessing the patient and documenting services in the patient’s record. Providers include only individuals who exercise independent judgment as to the services rendered to the patient during a visit. Only one provider who exercises independent judgment is credited with the visit, even when two or more providers are present and participate. If two or more providers of the same type divide up the services for a patient (e.g., a family physician [FP] and a pediatrician both see a child or an ObGyn and an FP both see a pregnant woman for different purposes) only one may be credited with a visit. In cases where a preceptor is following and supervising a licensed resident, credit would be given to the resident (see Table 5 instructions for further instruction on counting interns or residents). Where health center staff are following a patient in the hospital, the primary center staff person in attendance during the visit is the provider (and is credited with a visit), even if other staff from the health center and/or hospital are present. (Appendix A provides a listing of personnel. Only personnel designated as a “provider” can generate visits for purposes of UDS reporting.) With the exception of physicians, staff time may be allocated by 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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function among the major service categories based on time dedicated to other roles or functions (e.g., a nurse who dedicates 20 hours to medical care and 20 hours to providing health education each week would split full-time equivalent (FTE) between a medical Nurse and Health Educator. Table 5 provides further clarifications to these definitions. See page 52.) Providers may be employees of the health center, contracted staff, or volunteers. Contract providers, who are part of the scope of the approved program, are paid by the center with grant funds or program income, serve center patients, and document their services in the center’s records, are considered providers. (A discharge summary or similar document in the medical record will meet these criteria.) Also, contract providers paid for specific visits or services with grant funds or program income, who report patient visits to the direct recipient of a BPHC or BHW grant (e.g., under a migrant voucher program or contractors with homeless grantees) are considered providers and their activities are to be reported by the direct recipient of the BPHC or BHW grant. Since there is no time basis in their report, no FTE is reported for such individuals. Volunteer providers who serve center patients at the health center’s sites or locations under the supervision of the center’s staff and document their services in the center’s records are also considered providers. Their time is known and should be documented. Individuals or groups who provide services under agreement or contract where the health center does not pay for the visit are not credited as a health center visit regardless of whether or not they provide discharge summaries or report the service in the patient’s medical chart. These providers are generally noted in column III of the grant application Form 5A.

Full-Time Equivalent Staff

One full-time equivalent (FTE = 1.0) describes staff who individually or as a group worked the equivalent of full-time for one year. Each agency defines the number of hours for “full-time” work and may define it differently for different positions. For example, a physician can be hired as a full-time employee but only required to work nine 4-hour sessions (36 hours) per week. Similarly, clinicians may routinely stay late in the clinic or see hospitalized patients before or after normal work days. In either case, the clinician would still be considered to be 1.0 FTE. The full-time equivalent is based on employment contracts for clinicians and other exempt employees, and is adjusted for part-year employment. A FTE is calculated based on paid hours for non-exempt employees. FTEs are adjusted for part-time work or for part-year employment. In an organization that has a 40-hour work week (2,080 hours/year), a person who works 20 hours per week (i.e., 50% time) is reported as “0.5 FTE.” In some organizations different positions have different time expectations. Positions with different time expectations, especially clinicians, should be calculated on whatever they have as a base for that position. Thus, if physicians work 36 hours per week, this would be considered 1.0 FTE, and an 18 hour per week physician would be considered as 0.5 FTE, regardless of whether other employees work 40-hour weeks. A FTE is also based on the part of the year that the employee works. An employee who works full time for 4 months out of the year would be reported as “0.33 FTE” (4 months ÷ 12 months). Staff 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 assignment, under contract, or donated time. Interns, residents, and volunteers are counted consistent with their time with the health center and their licensing. (See Appendix B for further discussion.) Individuals who are paid by the health center on a fee-for-service basis only and do not have specific assigned hours, are not counted in the calculation of FTEs since there is no basis for determining their hours (However, the visits performed by fee-for-service 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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providers are still counted.).Individuals who are hired to “fill in” for staff who are on vacation or other paid leave are to be counted, in addition to the FTE for those who they are filling in for. It is assumed that more than 1.0 FTE will need to be employed by a health center if it staffs a position for five or six days a week, 52 weeks per year.

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Instructions by Table This section provides an overview of the UDS report and detailed instructions for completing each UDS table.

Overview of UDS Report The UDS includes two components: •

The Universal Report is completed by all health centers. This report provides data on services, staffing, and financing across all programs. The Universal report is the source of unduplicated data on health centers.

Grant Reports are completed by a sub-set of grantees who receive BPHC grants under multiple program authorizations. Only BPHC grantees supported with multiple 330 funding streams complete Grant reports. These reports repeat all or part of the elements of five of the Universal report tables. Grant reports provide comparable data for that portion of their program that falls within the scope of a project funded through a specific funding authority. Separate Grant reports are required for Migrant Health Center, Homeless Health Care, and Public Housing Primary Care grantees except for grantees funded under only one of these programs which receive no other 330-BPHC funding. No Grant report is submitted for the portion of multi-funded grantee’s activities supported by the Community Health Center Section 330(e) grant. Community Health Center (CHC) grant reporting is included in the Universal report. (The EHB is programmed to display only those tables that are required of a health center. If Grant tables are not required, they will not appear in the EHB.)

The Universal Report provides a comprehensive picture of all activities within the scope of BPHC-supported projects. In this report, health centers report on the total unduplicated number of patients and activities for the reporting year which are within the scope of projects supported by any and all primary care programs covered by the UDS. If out of scope services or sites are brought into scope during the calendar year, data for these sites and services are to be included for the full calendar year, back to January 1, not just for the period after the date of the scope change. For Grant Reports, grantees provide data on the patients and activities within that part of their program which is supported by a particular funding authority. Because a patient can receive services through more than one BPHC program, and not all grants are reported separately, totals from a health center’s multiple Grant reports cannot be aggregated to generate any meaningful total and might not equal the total on the Universal report. Once a patient has been identified as a recipient of any of the additional funding streams, all of the data for that patient are reported on the Grant tables. Thus, if a homeless patient is seen in the homeless medical van for medical services, all of their dental services and diagnoses will be counted on Tables 5 and 6A, even if the dental program is not specifically funded with BPHC Section 330(h) funds or identified in the budget for the homeless program. Health centers that receive funds under only one BPHC funding authority are required to complete only the Universal report and do not submit Grant reports. Health centers, funded through multiple BPHC funding authorities, complete a Universal report for the combined projects and a separate Grant report for each Migrant, Homeless, and/or Public Housing program grant. Examples include the following:

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A CHC grantee (section 330e) that also has Health Care for the Homeless support (section 330h) completes a Universal report and a Homeless Grant report, but does not complete a Grant report for the CHC grant.

A CHC grantee (section 330e) that also has Migrant Health (section 330g) and Homeless (section 330h) support, completes a Universal report, a Grant report for the Homeless program, and a Grant report for the Migrant program.

A grantee which is funded under the Health Care for the Homeless program (section 330h) and the Public Housing (section 330i) program completes a Universal report and two Grant reports—one for Homeless and one for Public Housing.

A grantee which is funded only under the Health Care for the Homeless program (section 330h) will file only a Universal report, and will not file a Grant report.

NOTE: The EHB reporting system will automatically identify the reports which must be filed and prompt the health center if some or all of the Universal or Grant report is left blank. Conversely, if a health center is not required to submit a specific Grant report that report will not appear in the EHB for completion. Apparent errors as to which reports are showing should be reported to the UDS Support Center at 866-UDS-HELP. The table below indicates which tables are included in the Universal report and Grant reports. Also listed are tables that have been deleted from the UDS since the system was initiated in 1996. No further reference to any of the deleted tables is made in this manual. Table

Data Reported

Universal Report

Service Area

Service Area

ZIP Code Table

Patients by ZIP Code by Health Insurance

Service Area

Cover Sheet

No longer reported

No longer reported

Table 1

No longer reported

No longer reported

Table 2

No longer reported

No longer reported

Patient Profile Table 3A

Patient Profile

Grant Reports Service Area

Patient Profile

Not reported for grant reports No longer reported No longer reported No longer reported Patient Profile

X

X

X

X

X

X

Staffing and Utilization

Staffing and Utilization

Staffing and Utilization

X

Table 5A

Tenure for Health Center Staff

X

Clinical

Clinical

Table 6A

Clinical Selected Diagnoses and Services

Not included in grant reports Clinical

X

X

Table 6B

Quality of Care Measures

X

Table 7

Health Outcomes by Race and Ethnicity

X

Table 3B Table 4 Staffing and Utilization Table 5

X

Patients by Age and Gender Patients by Hispanic/Latino Ethnicity and Race; Patients best served in a language other than English Selected Patient Characteristics Staffing and Utilization

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Not included in grant reports Not included in grant reports

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Table

Data Reported

Universal Report

Financial

Financial

Table 8A

Costs

Table 8B

No longer Reported

No longer reported

Table 9 (A-B-C)

No longer Reported

No longer reported

Table 9D

Patient-Related Revenue

Table 9E Other Forms

Other Revenue Other Forms EHR Capabilities and Quality Recognition

EHR Form

Financial X

X X Other Forms X

Grant Reports Financial Not included in grant reports No longer reported No longer reported Not included in grant reports Other Forms Not included in grant reports

Look-Alike Tables

Look-alikes are health centers which meet all Health Center Program requirements but do not receive a Health Center Program grant. Look-alikes submit the entire UDS report (see Appendix E for details). (The cells for reporting details of special populations and receipt of a BPHC grant will be grayed out and uneditable, but will still exist on the report.) Look-alikes are to follow all the same rules that are provided in this manual. There are a very small number of health centers which are Health Center Program grantees which also have one or more sites designated as a look-alike. These health centers will need to complete both grantee and look-alike UDS reports, limiting reporting to the approved scope of project for each respective program. Care must be taken to not include the same provider time, visits or associated costs in both reports, though it is expected that certain key staff (e.g., CEO, CFO, CMO, billing and collections staff) will have their time and cost allocated between the two programs and the two reports. It is possible that the same patient will be reported on both reports if that patient is seen at both the grantee and look-alike sites.

The Bureau of Health Workforce (BHW) Primary Care Clinics Tables

The BHW primary care clinics program is a separately funded program operated by the HRSA Bureau of Health Workforce. BHW primary care clinics submit UDS reports which are the same as that submitted by those funded under the Health Center Program. The BHW primary care clinics program is to follow all the same rules that are provided in this manual.

There are a very small number of Health Center Program grantees which are also funded through the BHW primary care clinics program. These health centers will need to complete both grantee and BHW primary care clinics UDS reports, limiting reporting to the approved scope of project for each respective program. Care must be taken to include only those aspects of the funded programs which are provided in their separate Notices of Award. It is possible that the same patient will be reported on both reports if the patient is seen in both programs or if the BHW primary care clinics program is included in the scope of the Health Center program. In the event the BHW primary care clinics program is included in the scope of the Health Center Program, the staff, patients, costs, income, and expenses of the BHW primary care clinics program will be included in the Health Center report.

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Instructions for ZIP Code Data The ZIP Code table provides demographic data on patients in the program, cross tabulating location (ZIP Code) by primary medical insurance status. It is completed by all health centers. Please note the following cross table checks: •

The sum of patients reported on the ZIP code table must equal Table 3A, Line 39, Column A + B (total patients by age and gender).

The total for Column B (Uninsured) must equal Table 4, Line 7, Column A + Column B.

The total for Column C (Medicaid, CHIP, and Other Public) must equal Table 4, Line 8 + 10, Column A + Column B.

The total for Column D (Medicare) must equal Table 4, Line 9, Column A + Column B.

The total for Column E (Private) must equal Table 4, Line 11, Column A + Column B.

Patients by ZIP Code

Health centers must report the number of patients served by ZIP code. This information enables BPHC to better identify areas served by health centers as well as minimize problems arising as a result of service area overlaps. Although patients may be mobile during the reporting period, health centers will report patients as of the most recent (last) ZIP code on file. It is the BPHC’s goal to identify residence by ZIP code for all patients served, but it is understood that residence information may be missing for a small number of patients. This is particularly true for centers that serve transient groups. Special instructions cover two of these groups: •

Homeless Patients: While many homeless patients live doubled up or in shelters, transitional housing, or other locations for which a ZIP code must be obtained, others— especially those living on the street—do not know or will not share an exact location. Where a ZIP code location cannot be obtained, or the location offered is questionable, health centers should use the ZIP code of the location where the patient is being served as a proxy. Similarly, if the patient has no other ZIP code and receives services on a mobile van, the ZIP code of the location where the van was parked that day should be used.

Migratory Agricultural Worker Patients: Many, if not most, migratory agricultural workers are seasonal workers and their address ZIP code they use when they are working in the community should be used, not their ‘downstream’ address. Migratory agricultural workers, on the other hand, may have a permanent residence in a community far from the location of their work and the site where they are receiving services. For the purpose of the UDS report, health centers are to use the ZIP code of the patient’s temporary housing location near the service delivery location. Patients, living in cars or on the land where a precise ZIP code is unavailable, should be reported using the ZIP code for the location (fixed site or mobile camp outreach) where they are being treated.

Foreign Nationals: Persons from other countries who are residing in the United States either permanently or temporarily are coded with their current US ZIP code. Tourists and other persons passing through the US may have a permanent residence outside the country, but are coded under “Other” ZIP Code.

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For the small number of patients for whom residence is not known, or for whom a proxy is not available, residence should be reported as “Unknown.” Although health centers are expected to report residence by ZIP code for all patients, it is recognized that large centers, as well as those located in tourist or hunting/fishing locations, may draw a significant number of patients from a large number of ZIP codes outside of their normal service area. To ease the burden of reporting, ZIP codes with ten or fewer patients may be aggregated and reported in the “Other” category.

Source of Insurance Medical insurance status must be obtained for all persons counted by the health center regardless of what services are provided. This means that individuals who only receive case management services, for example, must be queried as to their current medical insurance. Under no circ*mstances may they be shown as “uninsured” because they are not receiving a service that is covered by health insurance. Children seen in school based health center settings must have complete clinic intake forms which show insurance status, and ideally family income, before they can be counted as patients in the UDS. Note: The U.S. Census reports data on health insurance. These data are becoming available in the UDS Mapper at http://www.udsmapper.org/ and make it possible for health centers and BPHC to look more closely at the question of underserved areas. Now that public data show the number of uninsured persons and persons with Medicaid/State Children’s Health Insurance Program (CHIP) at the ZIP code level, it is meaningful to bring comparable data into the UDS system. This will permit even more sophisticated analyses of service area overlaps and enhance capabilities to identify areas which may need new access points. Insurance Definitions Health centers will report the patient’s primary health insurance covering medical care, if any, as of the last visit during the reporting period. Primary medical insurance is defined as the insurance plan/program that the health center would typically bill first for medical services. The categories for this table are slightly different than those on Table 4, lumping together Medicaid, CHIP and Other Public into one category. Some specific rules guide reporting: •

Patients who have both Medicare and Medicaid, would be reported as Medicare patients because Medicare is billed before Medicaid. In addition to being reported as Medicare patients, patients will also be reported as Dually Eligible. 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.

Medicaid, Medicare, and CHIP patients enrolled in a managed care program, which is operated by a Private insurance company, are still to be classified as Medicaid, Medicare or CHIP, as appropriate.

In rare instances, a patient may have an insurance which the health center cannot or does not bill. This may be a patient who is enrolled in Medicaid, but assigned to another primary care provider, or a patient with a Private insurance where the health centers’ providers have not been credentialed to bill that payer. In these instances the health center will still report the patient as being insured and will report the type of insurance, even if they cannot or did not bill this insurance.

Patients in correctional facilities may be classified as uninsured, whether seen in the correctional facility or at the health center and at the ZIP code of the jail or prison.

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Patients in residential drug programs, college dorms, military barracks, and the like are not classified as uninsured. In these instances, report the patient by type of insurance and record the ZIP code of the program, dorm, or barrack. •

Patients whose services are subsidized through State/Local Government “indigent care programs” are considered to be uninsured. Examples of State government “indigent care programs” include New Jersey’s Uncompensated Care Program, New York’s Public Goods Pool Funding, and Colorado’s Indigent Care Program.

No special category is to be used for patients whose insurance may be subsidized through the Affordable Care Act. They are classified in the insurance category of their third party payer.

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Questions and Answers for ZIP Code by Medical Insurance Reporting 1. Are there any changes to this table? No. 2. Do we need to collect information on and report on the ZIP Code of all of our patients? Yes. Although health centers are expected to report residence by ZIP code for all patients, it is recognized that large centers may draw a number of patients from a large number of ZIP codes which are outside of their normal service area. To ease the burden of reporting, ZIP codes with 10 or fewer patients may be aggregated and reported in an Other” category. 3. Do we need to collect information on and report on the primary medical insurance of all of our patients? Yes. Although the ZIP code of a patient may be unknown, medical insurance information must be obtained for every single person counted as a patient in the UDS report. 4. If a patient is not receiving medical care do we still need their medical insurance information? What about dental patients? Yes, medical insurance information is needed for all patients, even dental only patients. In order to understand the patient population being served, BPHC must know the medical insurance of all persons being counted in the program. 5. 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 Tables 3A, 3B, and 4.

The insurance totals reported on the ZIP code table must equal insurance reported on Table 4. Specifically, o

the total for Column B (Uninsured) must equal Table 4, Line 7, Column A + Column B,

o

the total for Column C (Medicaid, CHIP, Other Public) must equal Table 4, Line 8 + 10, Column A + Column B,

o

the total for Column D (Medicare) must equal Table 4, Line 9, Column A + Column B;

o

the total for Column E (Private) must equal Table 4, Line 11, Column A + Column B.

o

If ZIP code information is missing for some patients, residence should be reported as unknown.

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Table Patients by ZIP Code ZIP Code (a)

None/Uninsured (b)

Medicaid / CHIP / Other Public (c)

Medicare (d)

Private (e)

[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]

Other ZIP Codes Unknown Residence Total

Total Patients (f)

Note: This is a representation of the form. The actual online input process looks significantly different and the printed output from EHB may also be modified.

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Instructions for Table 3A and 3B Tables 3A and 3B provide demographic data on patients in the program and are included in both the Universal and Grant reports. All health centers must complete these tables. For the Universal Report, patients counted include all individuals who (1) received at least one face-to-face visit (2) during the calendar year (3) for services, as described below, (4) which are within the scope of any of the programs covered by UDS. Regardless of the scope or volume of services received, each patient is to be counted only once on Table 3A and only once in each of the two sections of Table 3B: race and ethnicity, and language, if applicable. The Grant Reports include those individuals who were counted in the Universal report who received at least one face-to-face visit within the scope of the specific grant program. As discussed above, patients are to be reported only once in each report filed; however, if the same patients are served in more than one program, they will be reported on the grant report for each program that served them. All patients reported on the Grant report will also be reported on the Universal report. A visit is face-to-face contact between a patient and a provider who exercises independent professional judgment in the provision of services to the patient, and the services rendered must be documented to be counted as a visit. See the “Definitions of Visits, Providers, Patients, and FTE” section (page 8) for complete definitions.

Table 3A: Patients by Age and Gender Report the number of patients by appropriate categories for age and gender. For reporting purposes, use the individual’s age on June 30, of the reporting period. Health centers are to report gender according to what the patient self-identifies as during patient registration. Note that on the non-prenatal portion of Tables 6B and 7, age is essentially defined as age on December 31. Thus, even if all the patients at a health center were medical patients, the numbers on Table 3A will not be the same as those on Tables 6B and 7, though they may be similar.

Table 3B: Patients by Hispanic or Latino Ethnicity / Race / Linguistic Barriers to Care Table 3B displays the race and ethnicity of the patient population in a matrix format. This permits the reporting of the racial identification of all patients including those who identify with the Hispanic/Latino population. Race and ethnicity are defined below.

Hispanic/Latino Ethnicity

Table 3B collects information on whether or not patients consider themselves to be of Hispanic/Latino ethnicity regardless of their race. •

Column A (Hispanic/Latino): Report the number of persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, broken down by their racial identification and including those Hispanics/Latinos born in the United States. Do not count persons from Portugal, Brazil, or Haiti whose ethnicity is not tied to the Spanish language.

Column B (Non-Hispanic/Latino): Report the number of all other patients except those for whom there are neither racial nor Hispanic/Latino ethnicity data. If a patient has

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chosen a race (described below) and not made a selection for the Hispanic / nonHispanic question, the patient is presumed to be non-Hispanic/Latino. •

Column C (Unreported/Refused to Report): Only one cell is available in this column. Report on Line 7, Column C only those patients who left the entire race and Hispanic/Latino Ethnicity part of the intake form totally blank.

Patients who self-report as Hispanic/Latino but do not separately select a race must be reported on Line 7, column A as Hispanic/Latino whose race is unreported or refused to report. Health centers may not default these patients to “White”, “Native American”, “more than one race”, or any other category.

Race

All patients must be classified in one of the racial categories (including a category for persons who are “Unreported/Refused to Report”). This includes individuals who also consider themselves to be “Hispanic or Latino.” Patients who self-report race, but do not separately indicate if they are “Hispanic/Latino," are presumed to be non-Hispanic/Latino and are to be reported on the appropriate race line in Column B. Patients sometimes categorized as “Asian/Other Pacific Islanders” in other systems are divided on the UDS into three separate categories: •

Line 1. Asian: Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Indonesia, Thailand, and Vietnam

Line 2a. Native Hawaiian: Persons having origins in any of the original peoples of Hawaii

Line 2b. Other Pacific Islanders: Persons having origins in any of the original peoples of Guam, Samoa, Tonga, Palau, Truk, Yap, or other Pacific Islands in Micronesia, Melanesia, or Polynesia

Line 2. “Total Hawaiian/Other Pacific Islander” must equal lines 2a+2b.

“American Indian/Alaska Native” (Line 4) includes persons who trace their origins to any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. “More than one race” (Line 6): “More than one race” should not appear as a selection option on your intake form. 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 which lists the races and tells the patient to “check one or more” or “check all that apply.” “More than one race” must not be used as a default for Hispanics/Latinos who do not check a separate race. They are to be reported on Line 7 (Unreported/Refused to Report), as noted above. NOTE: Health centers are required to report race and ethnicity for all patients. Some health centers’ patient registration systems were originally configured to capture data for patients who were asked to report race or ethnicity. Health centers who are unable to distinguish a White Hispanic/Latino patient from a Black Hispanic/Latino patient (because their system only asks patients if they are White, Black, or Hispanic/Latino), are instructed to report these Hispanic/Latino patients on Line 7, column A, as "unreported" race but include in the count of

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those with Hispanic or Latino ethnicity. Health centers must take steps to enhance their registration system to permit the capture and reporting of these data in the future.

Linguistic Barriers to Care

Health centers are designed to serve patients who face linguistic barriers to care, and are noted for having bi-lingual and multi-lingual staff as well as interpreters and translators. 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 Served in a Language other than English, may be estimated if the health center does not maintain actual data in its Electronic Health Record (EHR). If an estimate is required, the estimate should be based on a sample where possible. Note: This is the only place on the UDS where an estimate is accepted.

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Questions and Answers for Tables 3A and 3B 1. Have the data elements for Table 3B changed? No. 2. Our health center collects more robust race and ethnicity data than is required on the UDS. Why is the data limited? The UDS classifications are consistent with those used by the Census Bureau as per the October 30, 1997, Federal Register Notice entitled, ‘‘Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity,’’ issued by the Office of Management and Budget (OMB). These standards govern the categories used to collect and present Federal data on race and ethnicity. The 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, the OMB also 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. 3. How are patients of Hispanic/Latino ethnicity reported? Table 3B, race and ethnicity data is reported in a matrix. Patients who in other systems might be reported as Hispanic/Latino, independent of race, are reported in Column A of the UDS as Hispanic/Latino where you can also show the race of these patients. Patients are to be reported on Lines 1 through 7 depending on their race. If “Hispanic/Latino” is the only identification recorded in the center’s patient files, these patients will be reported in Column A on Line 7 as having an “Unreported” racial identification. 4. Can we just have a choice on our registration form of “more than one race”? No. In order to count a patient as being of “more than one race” they must have the option of checking two or more boxes under race and have indeed checked more than one. This methodology is the same as used in the census and mandated by OMB. 5.

How are individuals who receive different types of services or use more than one of our health centers’ service delivery sites reported, for example, a person who receives both medical and dental services, or a woman who receives primary care from one clinic site, but gets prenatal care at another? UDS Tables 3A and 3B provide unduplicated counts of patients. Health centers are required to report each patient once and only once on Table 3A and on Table 3B, regardless of the type or number of services they receive or where they receive them. Each person who has at least one visit reported on Table 5 is to be counted once and only once on Table 3A and on Table 3B. Visits are defined in detail in the “Definitions of Visits, Providers, Patients, and FTE” section (page 17). Note the following: •

Persons who receive WIC services and no other services at the agency are not to be counted as patients or reported on Table 3A or 3B (or anywhere on the UDS).

Persons who only receive imaging or lab services or whose only service was an immunization or screening test are also not to be counted as patients or reported on Table 3A or 3B (or anywhere on the UDS).

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6.

Our EHR changed during the year. Can we just add the information from the two systems together to report this table? No. Because the same patient might very well be counted in each system it would result in a potentially massive over-count this year, followed by a huge apparent reduction in patients the following year. It is the health center’s responsibility to ensure there is no duplication of data. Because this may be a time consuming process; it should be initiated as soon as the year ends to ensure sufficient completion time prior to the initial submission date.

7. Must the numbers on Tables 3A and 3B tie to UDS data reported on other tables? Yes. The sum of Table 3A, Line 39, Column A + B (total patients by age and gender) must equal Table 3B, Line 8 Column D (total patients by Hispanic/Latino Ethnicity and Race); Total Patients by ZIP Code; Table 4, Line 6 (total patients by income); and Table 4 Line 12, Column A + B (total patients by insurance status). The sum of Table 3A, Lines 1-18, Column A + B (total patients age 0-17 years) must equal Table 4, Line 12, Column A (total patients age 0-17 years). The sum of Table 3A, Lines 19-38, Column A + B (total patients age 18 and older) must equal Table 4, Line 12, Column B (total patients age 18 and older). 8.

Does race and Hispanic/Latino ethnicity of all our patients need to be collected and reported? Yes. The UDS requires the classification of race and Hispanic/Latino ethnicity information in order to assess health disparities across sub-populations. The format for the classification of this information has been stipulated by OMB, and the UDS manual follows the standards established by OMB. 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.

9.

I have a separate data system for my mental health patients. How do I include their data on these tables? Health centers are required to ensure their data is not duplicated so that the UDS report counts 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 in order to eliminate duplicates, or to check them manually. This can be a time consuming and potentially expensive process, and should be initiated as soon as the year ends to ensure sufficient time to complete it prior to the initial submission date.

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Table 3A: Patients by Age and Gender Reporting Period: January 1, 2015 through December 31, 2015

Male Patients (a)

Line Age Groups 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

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 25–29 Ages 30–34 Ages 35–39 Ages 40–44 Ages 45–49 Ages 50–54 Ages 55–59 Ages 60–64 Ages 65–69 Ages 70–74 Ages 75–79 Ages 80–84 Age 85 and over

Total Patients (Sum Lines 1–38)

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Female Patients (b)

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Table 3B: Patients by Hispanic or Latino Ethnicity/Race/Linguistic Barriers to Care Reporting Period: January 1, 2015 through December 31, 2015

Line

Patients By Race

1.

Asian

2a.

Native Hawaiian

2b.

Other Pacific Islander

2.

Total Hawaiian/Other Pacific Islander (Sum Lines 2a + 2b)

3.

Black/African American

4.

American Indian/Alaska Native

5.

White

6.

More than one race

7. 8.

Unreported/Refused to report race Total Patients (Sum Lines 1+2 + 3 to 7)

Patients by Hispanic or Latino Ethnicity Unreported/ NonTotal Hispanic/ Refused to Hispanic/ (d) Latino Report Latino (Sum Columns (a) Ethnicity (b) a+b+c) (c)

Line Patients by Language 12.

Patients best Served in a Language Other Than English

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Number (a)

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Instructions for Table 4: Selected Patient Characteristics Table 4 provides descriptive data on selected characteristics of health center patients. The table is included in both the Universal and Grant reports. All health centers report this table. For the Universal Report, include all patients receiving at least one face-to-face visit during the calendar year for services within the scope of any of the programs covered by UDS. The Grant Reports include only patients who received at least one face-to-face visit that was within the scope of the specific grant program. All patients reported on the Grant report will also be reported on the Universal report. This means that no cell in a Grant report may contain a number larger than the corresponding cell in the Universal report. Patients are to be reported only once per section in each report filed. The following cross table checks should be noted: •

ZIP Code Table, Column B must equal Table 4, Line 7, Column A + Column B.

ZIP Code Table, Column C must equal Table 4, Line 8 + 10, Column A + Column B.

ZIP Code Table, Column D must equal Table 4, Line 9, Column A + Column B.

ZIP Code Table, Column E must equal Table 4, Line 11, Column A + Column B.

The sum of Table 3A, Line 39, Column A + B (total patients by age and gender) must equal Table 3B, Line 8 Column D (total patients by race and Hispanic/Latino ethnicity); Table 4, Line 6 (total patients by income); and Table 4 Line 12, Column A + B (total patients by medical insurance status).

The sum of Table 3A, Lines 1-18, Column A + B (total patients age 0-17 years) must equal Table 4, Line 12, Column A (total patients age 0-17 years).

The sum of Table 3A, Lines 19-38, Column A + B (total patients age 18 and older) must equal Table 4, Line 12, Column B (total patients age 18 and older).

Income as a Percent of Poverty Level, Lines 1-6

Health centers are expected to collect income data on all patients, but are not required to collect this information more frequently than once during the year. If income information is updated during the year, report the most current information available. As a rule, family income is used. Except for minor-consent services, children will always be classified in terms of their parent’s income. Patients for whom the information was not collected within a year of their last visit must be reported on Line 5 as unknown. Do not attempt to allocate patients with unknown income. Although it may be known that a patient is homeless or a migratory agricultural worker or on Medicaid, it is not adequate to classify that patient as having an income below the poverty level. Income is defined in ranges relative to the Federal poverty guidelines (e.g., 100 percent and below the Federal poverty level). In determining a patient’s income relative to the poverty level, health centers should use official poverty guidelines defined and revised annually. The official Poverty Guidelines are published in the Federal Register during the first quarter of each year. The guidelines for CY 2015 are available online at http://aspe.hhs.gov/poverty/15poverty.cfm. Every patient reported on Table 3A must be reported once (and only once) on Table 4 Lines 1 through 5. The sum of Table 3A, Line 39, Column A + B (total patients by age and gender) must equal Table 4, Line 6 (patients by income). The same is true for Grant reports. 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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Principal Third Party Medical Insurance Source, Lines 7-12

This portion of the table provides data on patients classified by their age and the primary source of insurance for medical care. A patient’s health insurance may change during the year. Report on this table the primary medical insurance the patient had at the time of their last visit regardless of whether or not that insurance was billed for or paid for any or all of the visit services. (Other forms of insurance, such as dental or vision coverage, are never to be reported.) Patients are divided into two age groups: 0–17 (Column A) and age 18 and older (Column B) based on their age on June 30. Primary patient medical insurance is divided into seven types as follows. Uninsured (Line 7) Patients who did not have medical insurance at the time of their last visit are counted on Line 7. This may include patients whose visit was paid for by a third party source that was not an insurance, such as EPSDT, BCCCP, Title X, or some State or local safety net program. Do not count patients as uninsured just because their medical insurance did not pay for their visit. For example: •

A patient with Medicare who was seen for a dental visit which was not paid for by Medicare is still classified as having Medicare for this table.

A patient with Private insurance that has a $2000 deductible but had not yet reached that deductible is still considered a Private insurance patient.

A Medicaid patient who is assigned to another provider such that the health center cannot bill Medicaid for the visit is still classified as having Medicaid.

Children seen in a school based program who do not know their parent’s health insurance status must obtain that information if they are to be included in the count of patients. The only exception is for a minor-consent service permitted in the State, such as family planning or mental health services, in which case the minor child’s status may be recorded as uninsured if s/he does not have access to the parent’s information.

A patient with Medicaid, Private, or Other Public dental insurance may be presumed 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, and the health center must obtain this information from the patient.

Medicaid (Line 8a, 8b, and 8) State-run programs operating under the guidelines of Titles XIX (and XXI as appropriate) of the Social Security Act; Medicaid includes programs called by state-specific names (e.g., California’s “Medi-Cal” program). In some States, the Children’s Health Insurance Program (CHIP) is also included in the Medicaid program—see below. While Medicaid coverage is generally funded by Federal and State funds, some States also have “State-only” programs covering individuals ineligible for Federal matching funds (e.g., general assistance recipients or pregnant women) and these individuals are also reported as having Medicaid on Lines 8a or 8b and 8. NOTE: Individuals who are enrolled in Medicaid but receive services through a private managed care plan that contracts with the State Medicaid Agency are still reported as “Medicaid," not as Privately insured. NOTE ALSO: Patients enrolled in both Medicaid and Medicare are reported on lines 9 and 9a, not on any of the Medicaid lines, even if Medicaid pays the majority of the bill.

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S-CHIP or CHIP or CHIP-RA (Line 8b or 10b) The State Children’s Health Insurance Program, covered in statute by the Children’s Health Insurance Program Reauthorization Act (also known as 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 reported on line 8b) and/or through contracts with private insurance plans (reported on line 10b.) CHIP-Medicaid (Line 8b) In States that make use of Medicaid to handle the CHIP program, it is sometimes difficult or even impossible to distinguish between “regular Medicaid” and “CHIP-Medicaid.” In other States the distinction is readily apparent (e.g., they may have different appearing 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 from the State and/or county on their coding practice. If there is no way to distinguish between regular Medicaid and CHIP Medicaid, classify all covered patients as “regular” Medicaid (Line 8a). Medicare (Line 9) Federal insurance program for the aged, blind, and disabled (Title XVIII of the Social Security Act). Patients who have Medicare and Medicaid or Medicare and a private (“MediGap”) insurance are reported on line 9. In addition, those who have both Medicare and Medicaid (but not those with MediGap insurance) will be reported on line 9a (see below). Persons enrolled in “Medicare Advantage” products may have their services paid for by a private insurance company, but are counted as Medicare on line 9. Dually Eligible Medicare and Medicaid (Line 9a) Patients who have Medicare and Medicaid insurance are to be reported on line 9a. Do not include MediGap enrollees. This line is a subset of line 9 (Medicare) and patients who are dually eligible are to be reported on line 9a and included in the total on line 9, Medicare. Other Public Insurance (Line 10a) State and/or local government programs, such as Washington’s Basic Health Plan or Massachusetts’ Commonwealth plan, providing a broad set of benefits for eligible individuals; include public paid or subsidized private insurance not listed elsewhere. ACA Medicaidexpansion programs using Medicaid funds to help patients purchase their insurance through exchanges are classified as Medicaid (line 8a), if it is possible to identify them, otherwise they are to be reported as Private (line 11). Do not include any CHIP, Medicaid, or Medicare patients on Line 10a. Do not include uninsured individuals whose visit may be covered by a public source with limited benefits, such as the Early Prevention, Screening, Detection and Treatment (EPSDT) program, the Breast and Cervical Cancer Control Program (BCCCP), ADAP pharmaceutical coverage for HIV patients, etc. Also, do not include persons covered by workers’ compensation, as this is not health insurance for the patient, it is liability insurance for the employer. Other Public (CHIP) (Line 10b) In those States where CHIP is contracted through a private third party payer, participants are to be classified as “other public-CHIP” (Line 10b), not as private, even if the third party is, in fact, a traditional third party payer such as Blue Cross. CHIP programs which are run through the private sector, are often covered through HMOs. The coverage may appear to be a private insurance plan (such as Blue Cross/Blue Shield) but is funded through CHIP and counted on 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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Line 10b. Do not include patients who have insurance through the State insurance exchange regardless of whether or not their premium cost is subsidized in whole or in part under the ACA. Private Insurance (Line 11) Health insurance provided by commercial and not for profit companies; individuals may obtain insurance through employers or on their own. This includes persons who purchase insurance through the ACA-supported Federal or State exchanges. In those States that are making use of Medicaid expansion to support purchase of insurance through exchanges, the patients covered under these plans are to be reported as Medicaid, line 8a. If patients are not otherwise identifiable as Medicaid patients, they are to be reported as Private, line 11. Private insurance includes insurance purchased for public employees or retirees, such as Tricare, Trigon, the Federal Employees Benefits Program. Every patient reported on Table 3A must be reported once (and only once) on Lines 7 through 11. Note that there is no “unknown” insurance classification on this table—BPHC requires that health centers obtain medical insurance information from all patients in order to maximize third party payments. The following cross table checks should be noted: •

ZIP Code Table, Column B must equal Table 4, Line 7, Column A + Column B.

ZIP Code Table, Column C must equal Table 4, Line 8 + 10, Column A + Column B.

ZIP Code Table, Column D must equal Table 4, Line 9, Column A + Column B.

ZIP Code Table, Column E must equal Table 4, Line 11, Column A + Column B.

The sum of Table 3A, Line 39, Column A + B (total patients by age and gender) must equal Table 3B, Line 8, Column D (total patients by race and Hispanic/Latino ethnicity); Table 4, Line 6 (total patients by income); and Table 4, Line 12, Column A + B (total patients by medical insurance status).

The sum of Table 3A, Lines 1-18, Column A + B (total patients age 0-17 years) must equal Table 4, Line 12, Column A (total patients age 0-17 years).

The sum of Table 3A, Lines 19-38, Column A + 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, Column A + B (total patients by age and gender) must equal Table 4, Line 12 Column A + B (total patients by insurance status).

The same is true for Grant reports.

Source of Insurance

Health centers should report the patient’s primary health insurance covering medical care, if any, as of the last visit during the reporting period. Primary insurance is defined as the insurance plan/program that the health center would normally bill first for routine medical services rendered. NOTE: Patients, who have both Medicare and Medicaid, would be reported as Medicare patients, line 9, because Medicare is billed before Medicaid. In addition to reporting these patients on line 9 as Medicare, these patients will be reported on line 9a, Dually Eligible. 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.

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In rare instances a patient may have an insurance which the health center cannot or does not bill. This may be a patient who is enrolled in Medicaid, but assigned to another primary care provider or a patient with private insurance where the health centers’ providers are not on that payer’s panel. In these instances the health center will still report the patient as being insured and report the type of insurance. Patients served in correctional facilities may be classified as uninsured unless they have some form of insurance such as Medicaid or Medicare, whether seen in the correctional facility or at the health center. This is not the case with persons in other facility settings, such as those in residential drug programs, college dorms, military barracks, and the like. In these instances, health centers must obtain their coverage information and report the patients by their medical insurance, if they have insurance, not as uninsured. Similarly, patients whose services are subsidized through State/local government “indigent care programs” are considered to be uninsured. Examples of State government “indigent care programs” include New Jersey’s Uncompensated Care Program, New York’s Public Goods Pool Funding, and Colorado’s Indigent Care Program. For both Medicaid and Other Public Insurance, the table distinguishes between “regular” enrolled patients and patients enrolled in CHIP. •

Medicaid: Line 8b includes Medicaid-CHIP enrolled patients only; Line 8a includes all other enrolled patients; and Line 8 is the sum of 8a + 8b.

Other Public: Line 10b includes CHIP enrolled patients who are covered by a plan other than Medicaid; Line 10a includes all other persons with other public insurance (Health centers are asked to describe the programs so the UDS Reviewer can make sure that the classification of the program as Other Public is appropriate.); and Line 10 is the sum of 10a + 10b.

Managed Care Utilization, Lines 13a-13c

This section provides data on managed care enrollment during the calendar year and, specifically, reports on patient member months in managed care plans. Do not report in this section enrollees in Primary Care Case Management (PCCM) programs or CMS PCMH Demonstration grants which pay a small monthly fee (usually $5 or less 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, though an enrollee who has medical and dental (for example) is counted. Member Months A member month is defined as 1 member being enrolled for 1 month. An individual who is a member of a plan for a full year generates 12 member months; a family of 5 enrolled for 6 months generates (5 × 6) 30 member months; etc. 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 and, in the event they have not been saved, should request duplicates early so as to permit timely filing of the UDS report. Member Months for Managed Care (Capitated) (Line 13a): Enter 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 Health Maintenance Organization (HMO) or Accountable Care Organization (ACO) stipulates that for a flat payment per month, the health center will perform all of the services on a negotiated list. (Oregon 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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programs should include enrollees in coordinated care organizations (CCOs) on this line.)This usually includes, at a minimum, all office visits. Payments are received (and reported on table 9D) regardless of whether any service is rendered to the patient in that particular month. In the case of Medicaid, Medicare, and CHIP-RA, it is common for there to be a second “wrap-around” payment for managed care visits to adjust total payment to FQHC/PPS rates. Member Months for Managed Care (Fee-for-Service) (Line 13b): Enter 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 service delivery provider (at the health center) for 1 month during which time the patient may receive basic primary care services only from the health center, but for whom the services are paid on a fee-for-service basis. NOTE: It is common for patients to have their primary care covered by capitation, but other services, such as behavioral health or pharmacy, paid separately on a fee-forservice 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. NOTE ALSO: If patients are enrolled in a managed care program that permits them to receive care from any of a number of providers, including the health center and its providers, this is not to be considered managed care, and no member months are reported in this situation. Total Member Months (Line 13c): Enter the total of Lines 13a + 13b. As a rule, there is a relationship between the member months reported on Lines 13a and 13b and the insured persons on Lines 7 through 11. It would be unusual (though not impossible) for the number of member months for any one payer (e.g., Medicaid) to exceed 12 times the number of Medicaid patients reported on Line 8. As a rule, there is a relationship between the capitated member months reported on Line 13a and the net capitated income reported on Table 9D on Lines 2a, 5a, 8a, and/or 11a. Similarly, one can generally expect a relationship between the fee-for-service member months reported on Line 13b and the income reported on Table 9D on Lines 2b, 5b, 8b, and/or 11b.

Targeted Special Populations, Lines 14-26

This section asks for a count of patients from targeted special populations including persons who are homeless, migratory and seasonal agricultural workers, patients who are served by school based health centers, public housing patients, and patients who are veterans. Grantees who receive targeted funding for these populations also provide additional information on their seasonal and/or housing characteristics. Migratory or Seasonal Agricultural Workers and their Family Members, Lines 14–16 All health centers are required to report either on Line 16 or on lines 14 and 15 the number of patients seen during the reporting period who were either migratory or seasonal agricultural workers or their family members, or other individuals described in the statute at Section 330(g)(1)(B). (See definitions below.) Only Section 330(g) Migrant Health Center grantees

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provide separate totals for migratory and for seasonal agricultural workers on Lines 14 and 15. For Section 330(g) grantees, Lines 14 + 15 = Line 16. Definitions of Migratory and Seasonal Agricultural Workers: •

Migratory Agricultural Workers: Defined by section 330(g) of the Public Health Service Act, a migratory agricultural worker is an individual whose principal employment is in agriculture and who establishes a temporary home for the purposes of such employment. Migratory agricultural workers are usually hired laborers who are paid piecework, hourly, or daily wages. The definition includes those individuals who have 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 that agricultural workers who leave a community to work elsewhere are classified as migratory workers in their home community as are those who migrate to a community to work there. Aged and Disabled Former Agricultural Workers: As defined in Section 330 (g)(1)(B), aged and disabled former agricultural workers are individuals who have previously been migratory agricultural workers but who no longer work in agriculture because of age or disability. These individuals and family members of such individuals are included in Line 14.

Seasonal Agricultural Workers: Seasonal agricultural workers are individuals 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 employment. Seasonal agricultural workers are usually hired laborers who are paid piecework, hourly, or daily wages. The definition includes those individuals who have been so employed within 24 months of their last visit and their family members who may be patients of the health center.

For both categories of workers, the term agriculture means farming in all its branches, as defined by the OMB-developed North American Industry Classification System (NAICS), and includes seasonal workers included in the following codes and all sub-codes within: 111, 112, 1151, and 1152. Homeless Patients, Lines 17-23 All health centers are to report the total number of patients, known to have been homeless at the time of any service provided during the reporting period, on lines 17 – 22 or on Line 23. Only Section 330(h) Homeless Health Center grantees provide separate totals for patients by housing location Lines 17 - 22. Homeless Patients are defined as patients who lack 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. Section 330(h) Homeless Program grantees will provide separate totals for homeless program patients by the type of shelter arrangement the patient had when they were first encountered during the reporting year. For section 330(h) grantees Line 23 will be automatically calculated and will equal the sum of Lines 17 through 22. In categorizing patients for Lines 17 through 22:

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The shelter arrangement reported is the patient’s arrangement as of the first visit during the reporting period. This is normally assumed to be where the person was housed the prior night.

Persons who spent the prior night incarcerated, in an institutional treatment program (mental health, substance abuse, etc.) or in a hospital should be reported based on where they intend to spend the night after their visit/release. If they do not know, report them on Line 20: Street.

Patients currently residing in a jail or an institutional treatment program are not considered to be homeless until they are released to the street with no housing arrangement.

Line 17 – Shelter: Patients who are living in an organized shelter for homeless persons at the time of their first visit; shelters that generally provide for meals as well as a place to sleep, are seen as temporary, and often have a limit on the number of days or the hours of the day that a resident may stay at the shelter.

Line 18 – Transitional Housing: Transitional housing units are generally small units (six persons is common) where persons who leave a shelter are provided extended housing stays—generally between 6 months and 2 years—in a service rich environment. Transitional housing provides for a greater level of independence than traditional shelters, and may require that the resident pay some or all of the rent, participate in the maintenance of the facility and/or cook their own meals. Count only those persons who are “transitioning” from a homeless environment. Do not include those who are transitioning from jail, an institutional treatment program, the military, schools or other institutions.

Line 19 – Doubled Up: Patients who are living with others; the arrangement is generally considered to be temporary and unstable, though a patient may live in a succession of such arrangements over a protracted period of time.

Line 20 – Street: This category includes patients who are living outdoors, in a car, in an encampment, in makeshift housing/shelter, or in other places generally not deemed safe or fit for human occupancy.

Line 21 – Other: This category may be used to report previously homeless patients who were housed when first seen, but who were still eligible for the program. (HCH rules permit patients who are no longer homeless as a result of becoming residents of permanent housing to continue to be seen for 12 months after their last visit as homeless persons.) Patients who reside in SRO (single room occupancy) hotels or motels, other day-to-day paid housing, as well as residents of permanent supportive housing or other housing programs that are targeted to homeless populations should also be classified as “other,” on Line 21.

School Based Health Center Patients, Line 24 All health centers that identified a school based health center as a service delivery site in their grant or designation application and scope of project description are to report the total number of patients who received primary health care services at the school service delivery sites(s) listed. A school based health center is a health center located on or near school grounds, including pre-school, kindergarten, and primary through secondary schools, that provides onsite comprehensive preventive and primary health services. Services are targeted to the students at the school, but may also be provided to their children, siblings, or parents, and may occasionally include persons residing in the immediate vicinity of the school. Do not include 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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students who receive screening services or mass treatment such as vaccinations or fluoride treatments at a school as patients. Veterans, Line 25 All health centers report the total number of patients served who have been discharged from the uniformed services of the United States. It is expected that this element will be included in the patient information/intake form at each center. Report only those who affirmatively indicate they are veterans. Persons who do not respond or who have no information are not counted, regardless of other indicators. Persons, who are still in the uniform services, including soldiers on leave and National Guard members not on active duty, are not considered veterans. Veterans of other nations’ military are not counted here, even if they served in wars in which the United States was also involved. This category is not exclusive and an individual who is classified as a homeless patient (for example) can also be classified as a veteran. Public Housing, Line 26 All health centers should report on public housing patients, consistent with the reporting practice for other statutorily required special populations. Patients should be counted as residents of public housing if they are served at health center sites that meet the statutory Public Housing Primary Care (PHPC) definition (located in or immediately accessible to public housing) regardless of whether the health center site receives PHPC funding. Public housing means 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. For information on public housing, please see the HUD Website at http://portal.hud.gov/hudportal/HUD?src=/program_offices/public_indian_housing/programs/ph.

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Questions and Answers for Table 4 1.

Are there any changes to this table? Yes. Patients who have both Medicare and Medicaid insurance (commonly referred to as Dually Eligible or Medi-Medi) are to be reported on line 9a, Dually Eligible, in addition to line 9, Medicare. They are not reported on line 8 – Medicaid. This new line 9a, Dually Eligible, is a sub set of the total patients reported on line 9, Medicare.

2.

If we do not receive direct support under the Health Care for the Homeless, Agricultural Worker Health, or Public Housing Primary Care programs, do we need to report the total number of special population patients served? Yes. All health centers, regardless of whether they receive targeted grant funding for special populations, are required to complete Line 16 (the total number of patients seen during the reporting period who were agricultural workers or their dependents), Line 23 (total number of patients known to have been homeless at the time of any service during the year), Line 24 (patients of an approved, in-scope school based clinic), and Line 26 (total number of patients served in a public housing health center)—regardless of whether or not special funding was ever obtained for that clinic), and Line 25 (Veterans). Health centers who did not receive homeless funding are not required (or able) to complete the shelter arrangement details on Lines 17-22. They enter the total only. Health centers who did not receive agricultural funding are not required (or able) to complete the agricultural worker details on Lines 14 and 15. They enter the total only.

3.

Must 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.

4.

We have never collected information on whether or not a patient is homeless, living in public housing, an agricultural worker, or a veteran. Do we have to do this now for reporting? Yes. All health centers are required to ask every patient who visits their health center whether or not s/he is included in one of these special populations and to add this as an item on the patient’s profile so it can be reported. See below for specific instructions on reporting of public housing patients.

5.

Who are we to report as Public Housing Patients on line 26? Report the total number of patients who are served at any health center site located in or immediately accessible to public housing, regardless of whether or not the site is actually funded under section 330(i). The center would serve a preponderance of public housing resident, though others living close by can also use the center.

6.

If a patient is seen only for dental care, do we report the patient’s dental insurance on lines 7–12? No. Table 4 reports the medical coverage that health center patients have. All health centers must collect medical coverage information from all patients even if the patient is not seeking medical services. NOTE: If a patient has Medicaid, Private, or Other Public dental insurance you may presume that they have the same kind of medical insurance. If they do not have dental insurance you may not assume that they are uninsured for medical care, and must obtain this information from the patient.

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7.

Homeless and agricultural worker patients generally do not have income verification. Can we report them as having income below poverty? No. You can show them as having unreported income, but not as being below poverty unless you actually verify this at least annually. On the other hand, subject to your health center’s financial policies and procedures, you may document their income in your system based on their verbal statement of their income, and not require documents to prove this.

8.

We serve students at the school based clinic. 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 below poverty and uninsured? Not unless they are only receiving “minor consent services.” Minor consent services are limited to a very specific range of services such as contraception, STDs, and mental health services. These are defined in state law and not all states provide for them. For all other services, the children will require parental consent and the consent should also obtain information about income and insurance. 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. You may also accept their assertion of income without documentation or, if you do not get it, show the child as having unknown income. The patient’s health insurance is required even if it is not billed.

9.

Our state is using the ACA’s Medicaid Expansion provisions to assist patients with buying Private insurance. Should we count them as Medicaid or Private? As long as they can be identified as Medicaid expansion patients, they should be reported as Medicaid, line 8a. (This may require looking for specific plan numbers or other identifying characteristics in their insurance enrollment.) If and only if you are unable to identify Medicaid Expansion patients, report them as Private, line 11. Health centers may contact the UDS Support Line to learn if your State has expanded Medicaid through use of exchanges.

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Table 4: Selected Patient Characteristics Reporting Period: January 1, 2015 through December 31, 2015

Line

Characteristic

Number of Patients

Line

Income as Percent of Poverty Level

Number of Patients (a)

1. 2. 3. 4 5. 6. Line 7. 8a. 8b. 8. 9a. 9. 10a. 10b. 10. 11. 12.

100% and below 101–150% 151–200% Over 200% Unknown

TOTAL (Sum Lines 1–5)

Principal Third Party Medical Insurance

Regular 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 Lines 7 + 8 + 9 +10 +11)

13a. 13b.

Capitated Member months Fee-for-service Member months Total Member months (Sum Lines 13a + 13b)

14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.

18 and older (b)

Managed Care Utilization Payer Category

Line

0-17 years old (a)

None/Uninsured

Line

13c.

Medicaid (a)

Medicare (b)

Other Public Including NonMedicaid CHIP (c)

Special Populations Migratory (330g grantees only) Seasonal (330g grantees only) Total Agricultural Workers or Dependents (All Health Centers Report This Line) Homeless Shelter (330h grantees only) Transitional (330h grantees only) Doubling Up (330h grantees only) Street (330h grantees only) Other (330h grantees only) Unknown (330h grantees 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 Public Housing Patients (All Health Centers Report This Line)

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Private (d)

TOTAL (e)

Number of Patients (a)

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Instructions for Table 5: Staffing and Utilization This table provides a profile of health center staff (Column A), the number of visits they render (Column B), and the number of patients served in each service category (Column C). All health centers complete Table 5. Unlike Tables 3A, 3B, and 4, where an unduplicated count of patients is reported, Column C is designed to report the number of unduplicated patients within each of seven service categories: medical, dental, mental health, substance abuse, vision, other professional, and enabling. While the patient count is unduplicated within service categories, it will often involve duplication across service categories. The staffing information in Table 5 is designed to be compatible with approaches used to describe staff for financial reporting, while ensuring adequate detail on staff categories for program planning and evaluation purposes. (NOTE: Staffing data are reported only on the Universal table, not the Grant report tables.) For the Universal Report, all staff, all visits and all patients are reported in Columns A, B, and C. For the Grant Reports, only Columns B and C are to be completed. (Column A will appear “grayed out” in the computer version and printouts of the Grant report tables.) Every eligible visit must be counted on the Universal report, including all those reported in the Grant reports. Grant reports provide data on patients served in whole or in part with funds which are within the scope of one of the non-CHC programs and the visits which they had during the year. This includes all visits supported with either grant or non-grant funds. Note that, because Grant reports are sub-sets of the Universal report, no cell in a Grant report may contain a number larger than the corresponding cell in the Universal report.

Staff Full Time Equivalents (FTEs), Column A

Table 5 includes FTE staffing information on all individuals who work in programs and activities that are within the scope of the project for all of the sites covered by the UDS. (The FTE column is completed only on the Universal report. Staff is not separated according to the different BPHC funding streams.) All staff are to be reported in terms of annualized FTEs. A person who works 20 hours per week (i.e., 50% time in a 40-hour work week) is reported as “0.5 FTE.” Positions with less than a 40-hour base, especially clinicians, should be calculated on whatever they have as a base for that position. Agencies which have a 35-hour work week would consider 17.5 hours worked to be 0.5 FTE. Similarly, an employee who works 4 months out of the year would be reported as “0.33 FTE” (4 months ÷ 12 months). (See the “Full-Time Equivalent Employee” section, page 24 of this manual for detailed instructions on calculating FTEs.) Staff 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 assignment, under contract, or donated time. Thus, FTEs reported on Table 5 Column A include paid staff, volunteers, contracted personnel (paid based on worked hours or FTE), interns, residents, and preceptors. Individuals who are paid by the health center on a feefor-service basis only are not counted in the FTE column since there is no basis for determining their hours, though their visits are still reported in Column B, and the patients who received services are reported in Column C. All staff time is to be allocated by function among the major service categories listed. For example, a full-time nurse who works solely in the provision of direct medical services 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, time would be allocated as 0.25 FTE case manager (Line 24) and 0.75 FTE nurse (Line 11). Do not, however, attempt to parse out the components of an interaction. The nurse who handles a referral after a visit as a part of that visit would not be allocated out of nursing. 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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The nurse who collects vitals on a patient, who is then placed in the exam room, and later provide 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. An individual who is hired as a full-time clinician must be counted as 1.0 FTE regardless of the number of “direct patient care” or “face-to-face hours” they provide. Providers who have released time to compensate for on-call hours or who receive paid leave for continuing education or other reasons are still considered full-time if this is how they were hired. (Similarly, providers who routinely are required to work more than 40 hours per week are not counted as more than 1.0 FTE.) The time spent by providers performing tasks in what could be considered “non-clinical” activities, such as charting, reviewing labs, filling or renewing prescriptions, returning phone calls, arranging for referrals, participating in quality improvement (QI) activities, supervising nurses, etc., is counted as part of their overall medical care services time and not in some 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 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 staff, chairing or attending clinical meetings, or writing clinical protocols. Staff by Major Service Category Staff members are distributed into categories that reflect the types of services they provide. Major service categories include: medical care services, dental services, mental health services, substance abuse services, vision services, other professional health services, pharmacy services, enabling services, other program related services, non-clinical support, and facility. 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 1-15) • Physicians (Lines 1–7): M.D.s and D.O.s, except psychiatrists, ophthalmologists, pathologists, and radiologists; (Psychiatrists, ophthalmologists, pathologists, and radiologists are reported separately on Lines 20a, 22a, 13, and 14 respectively.) Licensed interns and residents are reported on the line designated for the specialty designation they are working toward and credited with their own visits. (Thus, a family practice intern is counted as a family physician on Line 1.) Naturopaths, acupuncturists, community health aides/practitioners, and chiropractors are not counted on these lines. These providers are reported on Line 22 as Other Professionals. •

Nurse Practitioners (Line 9a): N.P.s and A.P.N.s, except psychiatric nurse practitioners who are included on Line 20b, Other Licensed Mental Health Providers, and CNMs who are reported on line 10.

Physician Assistants (Line 9b)

Certified Nurse Midwives (Line 10)

Nurses (Line 11)—Registered nurses, licensed practical and vocational nurses, home health and visiting nurses, clinical nurse specialists, and public health nurses.

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Nurse full time or dedicated time devoted specifically to medical care services is reported here. •

Laboratory Personnel (Line 13): Pathologists, medical technologists, laboratory technicians and assistants, phlebotomists; some or all of the time of licensed nurses may be in this category if they are delegated to this responsibility, but none of the time of a physician should be included here. No visits are recorded for these workers.

X-ray Personnel (Line 14): Radiologists, X-ray technologists, and X-ray technicians; physician time would not be included here even if they were taking x-rays or performing sonograms. No visits are recorded for these workers.

Other Medical Personnel (Line 12): Medical assistants, nurses’ aides, and all other personnel, including unlicensed interns or residents, providing services in conjunction with services provided by a physician, nurse practitioner, physician assistant, certified nurse midwife, or nurse. Staff who support the quality assurance/quality improvement or Electronic Health Records (EHR) program are reported as Other Medical Personnel to the extent that they are working with the medical part of the quality improvement (QI) system. If they are, for example, working with the dental QI system, they would be reported on line 18, etc. Do not report medical records and patient support staff here—they are reported on Line 32, Patient Support Staff. No visits are recorded for these workers.

NOTE: Quality Assurance/Quality Improvement and EHR Personnel: Individuals in any or all of the above positions may be involved in quality improvement or quality assurance and EHR activities. They will be classified on the line that describes their main responsibility, not on the “IT” line. Individuals fulfilling help-desk, training, and technical assistance quality assurance and/or EHR functions who do not have a position that places them on one of the other Medical lines are included as “other medical personnel”.

Dental Services (Lines 16-19) • Dentists (Line 16): General practitioners, oral surgeons, periodontists, and endodontists; note: dental health technicians are not classified here; they are reported on Line 18, Other Dental Personnel. •

Dental Hygienists (Line 17)

Other Dental Personnel (Line 18): Dental assistants, aides, and technicians; no visits are recorded for these workers.

Mental Health Services NOTE: Behavioral health services include both mental health and substance abuse services. Centers using the “Behavioral Health” designation need to divide their staff between Lines 20a through 20c and Line 21 [Substance Abuse Services], as appropriate, unless they choose to identify all services as Mental Health Services. •

Psychiatrists (Line 20a)

Licensed Clinical Psychologists (Line 20a1)

Licensed Clinical Social Workers (Line 20a2)

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Other Licensed Mental Health Providers (Line 20b): Including psychiatric social workers, psychiatric nurse practitioners, family therapists, and other licensed Master’s Degree prepared clinicians

Other Mental Health Staff (Line 20c): Unlicensed individuals, including “certified” individuals, who provide counseling, treatment, or support to mental health providers; unlicensed interns or residents in any of the professions listed on Lines 20a through 20b are counted on Line 20c, unless they possess a separate license that they are practicing under. (Thus, an L.C.S.W. doing a Psychology internship may be counted on the L.C.S.W. line.) Regardless of any billing practices at the center, these individuals are credited with their own visits and no other person is to be credited with these visits.

Substance Abuse Services (Line 21) Substance abuse workers, psychiatric nurses, psychiatric social workers, mental health nurses, clinical psychologists, clinical social workers, family therapists, and other individuals providing counseling and/or treatment services related to substance abuse; neither licenses nor credentials are required by the UDS – each center will credential its own providers according to its own standards. (NOTE: Behavioral health services include both mental health and substance abuse services. Centers using the “Behavioral Health” designation need to divide their staff between Mental Health Lines 20a through 20c and Substance Abuse Line 21, as appropriate.) Other Professional Health Services (Line 22) Other Professional Health Services includes a broad array of providers of care. Some common professions include occupational and physical therapists, dieticians, nutritionists, podiatrists, naturopaths, chiropractors, acupuncturists, and community health aides and practitioners. Optometrists, previously included on this line, are reported on Line 22b. NOTE: WIC nutritionists and other professionals working in WIC programs are reported on Line 29a, Other Programs and Services Staff. (A more complete list is included in Appendix A.) Services other than those listed above or in Appendix A must be described in a clear detailed statement. Health centers are encouraged to check the reporting of such services with the UDS Support Center or their UDS Reviewer. There is a “specify” box for this line that must be completed for all services. Explain the other professional health services as specifically as possible. Vision Services (Lines 22a-22d) Persons working in the area of eye care, specifically: •

Ophthalmologists (Line 22a): Medical doctors specializing in medical and surgical eye problems

Optometrists (Line 22b): Optometrists (O.D.)—non-physicians who largely perform vision correction exams and prescribe glasses for patients

Other Vision Care Staff (Line 22c): Ophthalmologist/Optometric assistants, aides, and technicians. No visits are recorded for these workers. Fitting glasses is not considered as a visit regardless of who performs the fitting.

Pharmacy Services (Line 23) Pharmacists (including clinical pharmacists), pharmacy technicians, pharmacist assistants, and others supporting pharmaceutical services; no visits are recorded for these workers on any lines of the UDS. Note that the time (and cost) of individuals spending all or part of their time in assisting patients to apply for free drugs from 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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pharmaceutical companies (Pharmacy Assistance Programs [PAP]) is to be reported under “Eligibility Assistance Workers,” on Line 27a. An individual employee who works as a pharmacy assistant (for example) and also provides PAP enrollment assistance should be allocated by time spent in each category. 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, no pharmacy visits are recorded on Table 5. Clinical pharmacists must be reported on Line 23 and may not be allocated to other clinical or non-clinical lines, nor may their interaction with patients be counted elsewhere. Enabling Services (Lines 24-29) Specific types of enabling services are listed below and are reported on Lines 24 through 28. “Enabling services,” and especially “other enabling services” (Line 28), are not to be used as a catch-all for services which are not included on other lines. Often such services belong on Line 29a (other related services) or are services which are not counted anywhere on the UDS. If a service does not fit the strict descriptions for Lines 24 through 27b, its inclusion on Line 28 must include a clear detailed statement of what is being reported. Health centers are encouraged to check such services with the UDS Support Center or their UDS Reviewer prior to submission. •

Case Managers (Line 24): Staff who assist patients in the management of their health and social needs, including assessment of patient medical and/or social service needs, and maintenance of referral, tracking, and follow-up systems; case managers may, at times, provide health education and/or eligibility assistance during the course of their case management functions. Staff includes individuals who are trained as, and specifically called, Case Managers, as well as individuals called Care Coordinators, Referral Coordinators, and other local titles. Nurses, social workers, and other professional staff who are specifically allocated to this task during assigned hours, may be included here, but not when these services are an integral part of their other function. (Thus, none of the time of a nurse providing comprehensive nursing support including making an appointment for a patient with another provider is counted here.)

Patient and Community Education Specialists (Line 25):Health educators, with or without specific degrees in this area; family planning specialists, HIV specialists, and others who provide information about health conditions and guidance about appropriate use of health services that are not otherwise classified under outreach may also be included here. Services may be one-toone with the patient or in a group; however, group visits are not reported in Column B.

Outreach Workers (Line 26): Individuals conducting case finding, education, or other services to identify potential patients or clients, and/or facilitate access or referral of potential health center patients to available health center services; no visits are recorded for these workers.

Transportation Workers (Line 27): Individuals who provide transportation for patients (van drivers) or arrange for transportation, including persons who provide for long distance transportation to major cities in some extremely remote clinic locations; no visits are recorded for these workers.

Eligibility Assistance Workers (Line 27a): All staff providing assistance in securing access to available health, social service, pharmacy, and other

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assistance programs, including Medicaid, Medicare, WIC, SSI, food stamps (SNAP), TANF, Pharmacy Assistance Programs, and related assistance programs; staff hired under the HRSA Outreach and Enrollment grants is included on this line. No visits are recorded for any of these workers. •

Interpretation Staff (Line 27b): Staff whose full time or dedicated time is devoted to translation and/or interpretation services. Do not include that portion of the time of a nurse, medical assistant, or other support staff who provides interpretation or translation during the course of his/her other activities. No visits are recorded for these workers.

Personnel Performing Other Enabling Service Activities (Line 28): All other staff performing enabling services not described above; there is a “specify” field that must be used to describe what these staff are doing. “Other enabling services” is not to be used as an all-inclusive category for services which are not included on other lines. Often such services belong on Line 29a (Other Programs and Related Services Staff) or are services which are not reported on the UDS. Be sure to include a clear detailed statement of what is being reported. Health centers are encouraged to check such services with the UDS support center or their reviewer. No visits are recorded for these workers.

Other Programs and Related Services Staff (Line 29a) Some health centers, especially “umbrella agencies,” operate programs which, while within their scope of service and often important to the overall health of their patients, are not directly a part of the listed medical, dental, behavioral, or other health services. These include 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 programs, fitness or exercise programs, public/retail pharmacies, etc. The staff members for these programs are reported under Other Programs and Related Services. There is a “specify” field that must be used to describe what these staff members are doing. No visits are recorded for these workers. Non-Clinical Support Services (Line 30a-32) • Management and Support Staff (Line 30a): Management team including Chief Executive Officer, Chief Financial Officer, Chief Information Officer, and Chief Medical Officer; other non-clinical staff and office support (secretaries, administrative assistants, file clerks, etc.) for health center operations within the scope of the program; in the case of the Medical Director or other individuals whose time is split between clinical and non-clinical activities, report only that portion of their full-time equivalent corresponding to the corporate management function. (See limits on non-clinical time above.) •

Fiscal and Billing Staff (Line 30b): Staff performing accounting and billing functions in support of health center operations for services performed within the scope of the program, excluding the Chief Financial Officer (who is reported on Line 30a)

IT Staff (Line 30c): Technical information, technology and information systems staff supporting the maintenance and operation of the computing systems that support functions performed within the scope of the program; staff managing the hardware and software of an EHR/EMR system are reported on Line 30c, but design of medical forms, data entry, and analysis of EHR data, as well as help-

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desk, training and technical assistance functions are included as part of the other medical personnel functions reported on Line 12. •

Facility Staff (Line 31): Staff with facility support and maintenance responsibilities, including custodians, housekeeping staff, security staff, and other maintenance staff; if facility functions are contracted (e.g., janitorial services) do not attempt to create an FTE, but the costs will be shown on the facility line on Table 8A.

Patient Services Support Staff (Line 32): Intake staff, front desk staff, and medical/patient records; eligibility assistance workers are reported on Line 27a, not here.

Note: The Non-Clinical category for this report is more comprehensive than that used in some other program definitions and includes all personnel working in a BPHC-supported program, whether that individual’s salary was supported by the BPHC grant or other funds included in the scope of project. Where appropriate, and when identifiable, staff included in a health center’s federally approved indirect cost rate should be reported here.

Relationship between Table 5 and Table 8A

Table 8A has data relating to cost centers. Staff classifications should be consistent with cost classifications. The staffing 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 strange (e.g., volunteers on Table 5 resulting in no cost on Table 8A or contractor costs on Table 8A with no corresponding FTEs on Table 5) be sure to include an explanatory note on Table 8A. The chart below illustrates the relationship between the two tables. FTEs Reported on Table 5, Line: 1–12: Medical providers and clinical support staff 13–14: Lab and X-ray 16–18: Dental (e.g., dentists, dental hygienists) 20a–20c: Mental Health 21: Substance Abuse 22: Other Professional (e.g., nutritionists, podiatrists) 22a–22c: Vision (ophthalmologists, optometrists, optometric assistants, other vision care) 23: Pharmacy 24–28: Enabling (e.g., case management, outreach, eligibility)—relationship of the detail follows. Note that the cost categories are not in the same sequential order as they appear on Table 5. 24: Case Managers 25: Patient/Community Education Specialists 26: Outreach Workers 27: Transportation Staff 27a: Eligibility Assistance Workers 27b: Interpretation Staff 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

Have Costs Reported on Table 8, Line: 1: Medical staff 2: Lab and X-ray 5: Dental 6: Mental Health 7: Substance Abuse 9: Other Professional 9a: Vision 8a: Pharmacy 11a–11g: Enabling 11a: Case Management 11d: Patient and Community Education 11c: Outreach 11b: Transportation 11e: Eligibility Assistance 11f: Interpretation Services 59

FTEs Reported on Table 5, Line: 28: Other Enabling Services 29a: Other programs and services (non-health related services including WIC, job training, housing, child care, etc.) 30a–30c and 32: Non-clinical support services including patient support (e.g., corporate, intake, medical records, billing, fiscal and IT staff) 31: Facility (e.g., janitorial staff)

Have Costs Reported on Table 8, Line: 11g: Other Enabling Services 12: Other Related Services 15: Non-Clinical Support Services 14: Facility

Clinic Visits, Column B

A visit is a documented, face-to-face contact between a patient and a provider who exercises his/her independent, professional judgment in the provision of services to the patient. (See “Definitions of Visits, Providers, Patients, and FTE” section, page 17, for further details on the definition of visits). Health centers report visits which occurred during the reporting year which were rendered by the staff identified in Column A, regardless of whether the staff is salaried, contracted or donated. No visits are reported for personnel who are not “providers who exercise independent professional judgment” within the meaning of the definition above. In addition, BPHC has chosen not to require reporting health centers to report on visits for certain other classes of staff, even if they do exercise professional judgment. The cells applicable to these staff (e.g., laboratory, transportation, outreach, pharmacy) are blocked out in Column B. Visits that are for administration of pharmaceuticals (such as Coumadin administration), follow up to care (such as return diabetes and hypertension checkups) and wound care (which are following up to the original primary care visit) would not count as per the definitions. In addition, group visits, allergy shots, lab tests (including Tb tests, Tb readings, pregnancy tests, BPs etc.) vaccinations, or prescription refills (including Depo-Provera shots) cannot be counted as visits. Visits that are purchased from non-staff providers on a fee-for-service basis are also counted in this column, even though no corresponding FTEs are included in Column A. To be counted, the visit must meet the following criteria: •

The service was provided to a patient of the health center by a provider that is not part of the health center’s staff (neither salaried nor contracted on the basis of time worked, but meeting the center’s credentialing policies),

The service was paid for in full by the health center, and

The service otherwise meets the above definition of a visit.

This category does not include unpaid referrals, referrals where a third party will make the payment (e.g., the patient’s insurance company) or referrals where only nominal amounts are paid though the negotiated payment may be less than the provider’s “usual, customary, and reasonable” rates. Referrals for services that would not be counted as visits if performed by health center’s staff are similarly not counted if provided under some other arrangement.

Patients, Column C

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the total number of patients served for each of the seven separate services listed below. Within each category, an individual can only be counted once as a patient. A person who receives multiple types of services should be counted once (and only once) for each service. For example, a person receiving only medical services is reported once (on Line 15) as a medical patient, regardless of the number of medical visits s/he may have had. A person receiving medical, dental, and enabling services is reported once as a medical patient (Line 15), once as a dental patient (Line 19), and once as an enabling patient (Line 29), but is counted only once on each line in column C, regardless of the number of visits reported in column B. An individual patient may be counted once (and only once) in each of the following categories: • • • • • • •

Medical services (Line 15) Dental services (Line 19) Mental health services (Line 20) Substance abuse services (Line 21) Vision services (Line 22d) Other professional services (Line 22) Enabling services (Line 29)

If you show visits in Column B for any of these seven categories, you are required to show the unduplicated number of patients who received these visits in Column C. Since patients must have at least one documented visit, it is not possible for the number of patients to exceed the number of visits. Also, individuals who only receive services for which no visits are generated (e.g., laboratory, imaging, pharmacy, transportation, outreach) are not included in the patient count reported in Column C. For example, individuals who receive outreach or transportation services are not included in the total number of patients receiving enabling services in Column C on Line 29; individuals who received flu shots but no other medical service are not counted as medical patients on Line 15.

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Questions and Answers for Table 5 1.

Are there changes to this table? No.

2.

How do I count participants in a group session? If you have group treatment sessions for substance abuse, mental health, or behavioral health you must record the visit in each participant’s chart. If interaction with an individual in a group is not recorded in a participant’s chart, that participant may not be counted as a patient and the interaction is not counted as a visit. Each patient charted in a group session must be billed and the service must be paid for consistent with agency policy either by the patient, their insurance, or another contract maintained by the health center. If some patients/visits are billed and others are not billed, only those which are billed may be counted. No group medical visits or health education visits are counted on the UDS. Though in some instances they may be billable, the UDS specifically does not count any group medical or education activities as visits in such sessions.

3.

How do I report the FTEs for a clinician who regularly sees patients 75 percent of the time and covers after-hours call for the remaining 25 percent of his/her salary? An individual who is hired as a full-time clinician must be counted as a 1.0 FTE clinician regardless of the number of “direct patient care” or “face-to-face hours” they provide. Providers who have released time to compensate for on-call hours or hours spent on clinical committees, or who receive leave for continuing education or other activities are still considered full-time if this is how they were hired. The time spent by a physician (for example) while not in face-to-face contact with the patient, such as charting, reviewing labs, filling prescriptions, returning phone calls, arranging for referrals, is not to be “adjusted off”—it is to be considered part of his/her time as a physician. The one 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 can be 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 staff, writing clinical protocols, designing formularies, approving specialty referrals. Note that loan-repayment recipients must be counted as full time. Note also that the FQHC Medicare intermediary has different definitions for full time providers. These definitions are not to be used in reporting on the UDS.

4.

Our physicians work 35-hour weeks. Are they reported as 87.5% (35 ÷ 40) FTEs? No; they are each counted as 1.0 FTE. Health centers are not required by BPHC to have a 40-hour work week, but whatever work week they have must be considered full time.

5.

Should the total number of patients reported on Table 3A be equal to the sum of the several types of service patients on Table 5? Not unless the only service you provide is medical services. On Table 5, the health center reports patients for each type of service, with the patient counted once for each type of service received. Thus, a person who receives both medical and dental services would be counted once as a medical patient on Line 15 and once as a dental patient on Line 19. Because there are seven different types of patients identified on Table 5, a patient who is counted only once on Table 3A may be counted up to seven different places on Table 5.

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6.

If I report costs for case management services on Table 8A, do I have to report case managers on Table 5? Usually. There should be a logical consistency between Table 5 and 8A. If a health center reports the costs for case management services one would expect to see case managers reported on Table 5, unless the service was contracted with no staff time specifically identified. Similarly, if there are staff members on Table 5 we would expect costs on Table 8A unless all of the staff are volunteers. Some services do not, in fact, involve staff. Spending funds on bus tokens, for example, would involve money on table 8a, but no staff on table 5.

7.

How are contracted providers and their activities reported on Table 5? If the contracted provider is paid on the basis of time worked (for example, one day a week), the FTE is reported on Table 5, Column A, as well as 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 provider is paid on a fee-forservice basis, no FTE is reported on Table 5 Column A, but visits and patients are reported. Note that this is likely to trigger an edit in the EHB data entry system which must be explained, but it is not an error.

8.

Where does “Behavioral Health” get reported? “Behavioral Health” in some systems is just another name for mental health, and the staff and visits are reported on Lines 20a through 20c. But some health centers have merged the roles of “Mental Health Provider” and “Substance Abuse Provider” into a single role which they call “Behavioral Health Provider.” In this instance, the health center has two choices. The first is to assert that substance abuse problems are, indeed, mental health problems, and classify its behavioral health staff as mental health staff on Lines 20a, 20a1, 20a2, 20b, or 20c. Another method would be to carefully record the time and activities of these dual function providers. In this case, the health center will need to identify each and every visit as either a mental health visit or a substance abuse visit so that the patients and visits can be correctly classified. It must also keep track of providers’ time so that its FTEs on Table 5 (and associated costs on Table 8A) can be accurately allocated and recorded.

9.

If a clinician provides mental health and substance abuse (behavioral health) services to the same patient during a visit, how should this be counted? Because “substance abuse” is also seen as a mental health diagnosis, it is permissible to count the visit as mental health. Under no circ*mstances would it be counted as “one of each.” The provider will also need to be classified as mental health for this visit as must be the cost of the provider on Table 8A. This does not apply to physicians, who would count the visit as a medical visit.

10.

Do I count the time of volunteer clinicians, interns or residents? Yes. Volunteers, (some) interns and residents are generally licensed practitioners and their time is counted just like 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 also the more complete discussion of counting volunteers, interns, and residents in Appendix B.

12.

We contract with a number of individuals who are licensed as physicians to “overread” our tests: an ophthalmologist reads the retinal photos that our medical

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assistant takes for our diabetic patients; a radiologist over-reads the x-rays that our x-ray tech takes; the outside laboratory’s pathologist officially provides the test results that come off their machines; and a consulting cardiologist receives our EKGs and confirms our findings. Should we report them as our staff? Do we count what they do as visits? Tests are not counted as visits anywhere in the UDS. Do not count the time (FTE) of any individual who is working on a contract basis where the payment is not for their time worked but rather, is for the activity that they performed. So these activities, all of which are important to the provision of comprehensive care to your patients, are not counted or reported separately. 13

We employ community health workers at our health center. Where are they reported? The title “community health worker” is used differently by different health centers, and often includes an individual performing multiple tasks within the same health center. The following table provides some guidance for reporting these staff. Count these workers on the line that most closely matches their work responsibilities. Services Performed

UDS Line / Title

Assisting medical providers by vitaling patients, placing them in exam rooms, and providing basic health screening services

12: Other medical

Assisting dental patients before, during, or after the visit by getting patient history and by chairing patients

18: Dental assistants, aides

Serving as a community health aide/practitioner (Alaska only)

22: Other professional

Working with vision patients before and after the visit by getting patient history, bringing patients to exam room and optical department

22c: Other vision care

Assisting patients in the management of their health and social needs

24: Case managers

Providing health education on topics related to chronic disease prevention, physical activity, and nutrition

25: Patient/community education

Conducting assessments and case findings and facilitating patient’s access to health center services

26: Outreach

Assisting new/returning patients to qualify for the health center’s sliding discounts or other benefit programs

27a: Eligibility assistance

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Table 5: Staffing and Utilization Reporting Period: January 1, 2015 through December 31, 2015

Line 1 2 3 4 5 7 8 9a 9b 10 10a 11 12 13 14 15 16 17 18 19 20a 20a1 20a2 20b 20c 20 21 22 22a 22b 22c 22d 23 24 25 26 27 27a 27b 28 29 29a 30a 30b 30c 31 32 33 34

Personnel by Major Service Category Family Physicians General Practitioners Internists Obstetrician/Gynecologists Pediatricians Other Specialty Physicians Total Physicians (Lines 1–7) Nurse Practitioners Physician Assistants Certified Nurse Midwives Total NPs, PAs, and CNMs (Lines 9a–10) Nurses Other Medical Personnel Laboratory Personnel X-ray Personnel Total Medical (Lines 8 + 10a through 14) Dentists Dental Hygienists Other Dental Personnel Total Dental Services (Lines 16–18) Psychiatrists Licensed Clinical Psychologists Licensed Clinical Social Workers Other Licensed Mental Health Providers Other Mental Health Staff Total Mental Health (Lines 20a–c) Substance Abuse Services Other Professional Services (specify___) Ophthalmologists Optometrists Other Vision Care Staff Total Vision Services (Lines 22a–c) Pharmacy Personnel Case Managers Patient/Community Education Specialists Outreach Workers Transportation Staff Eligibility Assistance Workers Interpretation Staff Other Enabling Services (specify___) Total Enabling Services (Lines 24–28) Other Programs/Services (specify___) Management and Support Staff Fiscal and Billing Staff IT Staff Facility Staff Patient Support Staff Total Facility and Non-Clinical Support Staff (Lines 30a–32) Grand Total (Lines 15+19+20+21+22+22d+23+29+29a+33)

FTEs (a)

Clinic Visits (b)

Patients (c)

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Instructions for Table 5A: Tenure for Health Center Staff Table 5A data are reported in the Universal report, only. It is completed by all health centers. This table provides information on the tenure of health center providers and key management staff, and they may be employed for all or a part of the year or by contract or retained as NHSC assignees. Staff is defined as falling into one of two categories—(1) Full and Part Time staff and (2) Loc*ms, On-call, and Others—as defined further below. The definitions for the each line (category) on Table 5A is the same as those used on Table 5, and individuals reported on the selected lines on Table 5A are the same individuals that are reported on the comparable lines on Table 5. Line numbers on Table 5A correspond to those on Table 5. Not all Table 5 lines are reported. Specifically, lines for non-providers, other than health center management staff, are excluded, as are providers of “Other Professional” and Enabling services.

Definitions Full and Part Time Staff, Column A

Full and part time staff are individuals who are considered regular employees of the health center. They may be paid in a number of different ways and may work different amounts of time. Future employment may be limited by the expiration of a contract or may be “open-ended” with no specific end date. The following are considered full and part time staff and are reported in Column A, with months in current position reported in Column B: Full Time Staff Are employed by the health center, receive benefits, have withholding taxes deducted from their paychecks, and have their income reported to IRS on a form W2. Staff may or may not have a contract. Staff are considered to be full time when they are so defined in their contract and/or when their benefits reflect this status. (For example, if full time employees get 8 hours off for a holiday, these staff also receive 8 hours off.) They may have assigned work hours which are less than 40 per week, and may actually end up working more than those assigned hours. Part Time Staff Are employed by the health center, but for less 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 IRS on a form W2. Staff may or may not have a contract. Staff are considered to be part time when they are so defined in their contract and/or when their benefits reflect this status. (For example, if a full time employee receives 8 hours off for a holiday, a 75% part time staff person would receive 6 hours off.) Part time staff may actually end up working more than their assigned hours. Part Year Staff Persons employed or contracted for full or part time for a specific period because of a recurring special need. This is especially common in centers that serve fishing fleets, agricultural workers, cannery workers, or recreation areas. To be included, they must either be working at the time of the census or be under agreement to return to the clinic in the following year. An individual who works for part of the year and then leaves prior to the last working day of the year with no concrete plan to return is not reported on this table. Contract Staff Are contracted by and work at the health center. They work regular assigned hours every day or week or month. They may or may not receive benefits appropriate to their FTE. They do not 66 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

have withholding taxes deducted from their paychecks and they have their income reported to IRS on a form 1099. Do not include contract physicians who are paid by the visit to deliver services in their own offices or hospitalists. NHSC Assignees Are members of the National Health Service Corps who are assigned by the Corps to the health center. This includes members of the “ready reserve.” These individuals are employees of the U.S. Government. The health center may or may not have a contract with the NHSC to pay a specific amount to cover some or all of the cost of their assignment.

Loc*ms, On-Call, and Other Service Providers or Consultants Column C

Health centers often make use of individuals other than their regular staff to provide services to patients. They have many different names though the difference between categories may be subtle or non-existent and different centers may use the names differently. For the purpose of this table, the following are considered loc*ms, on-call staff, etc., and are reported in Column C, with months in current position reported in Column D Locum Tenens Loc*ms work at a health center on an “as needed” basis. They are most commonly used to fill in for a part time absence of another provider (e.g., on a day off or to cover for a vacation, sick leave, FMLA) but may also be used when the center is unable to hire a full or part time staff person for a position and retained until the position is filled. Loc*ms 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 (though they may from the agency they work for) and generally are not covered by the health center’s professional liability insurance. Generally loc*ms cannot be hired by the center as a full or part time employee without paying a fee to the agency. On-call Providers On-call providers also work at a health center on an “as needed” basis, and are also most commonly used to fill in for a part time absence of another provider (e.g., on a day off or to cover for a provider who is on vacation, sick leave, FMLA) but may also be used for an extended period when the center is unable to hire a full or part time staff person for a position. Unlike loc*ms, on-call providers are paid by the health center. They may or may not receive benefits, and may or may not have payroll and income taxes withheld. On-call providers are generally not covered by Federal Tort Claims Act (FTCA) though they may be covered by the center’s gap insurance. Volunteers Health center volunteers may have a regular schedule which may include a large number of hours or just a few hours a month. They are generally scheduled by the session. Volunteer providers are not paid by the health center and do not receive benefits. They are not covered by FTCA though they may be covered by the center’s gap insurance. Residents/Trainees Many health centers are involved in training programs which involve the trainee providing services at the health center under the supervision of a more senior person. Many of these trainees (especially medical and dental residents) are licensed in their own right:

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In the case of medical residents, they are included on the line for which they are training, so a family practice resident will be counted on the family practice line, even though they have not yet passed the boards for that additional certification.

In the case of mental health interns or residents, those who are licensed at a level other than that for which they are training are eligible to be reported. A Psychology resident may be a Licensed Clinical Social Worker (LCSW), in which case they would be considered on the LCSW line.

An individual who is not licensed is not to be counted. A LCSW trainee who holds no independent license would not be reported on this table at all.

Off-site Contract Providers In some instances health centers contract for the services of providers who work at a location that is not an in-scope site as defined in their application. This may be because the center does not have the critical mass to be able to establish a service (e.g., a dental contract) or because it is serving a wider area than its existing sites can reach (especially in migrant voucher or homeless programs). •

If providers are contracted for a specific time (e.g., Monday and Wednesday afternoons or 2 days per week), they are to be considered for this table.

If providers are paid by the visit, they are not to be considered for this table.

Non-Clinical Consultants Some organizations—especially smaller and more remote organizations—use consultants to fill administrative, non-clinical management positions because they are unable to recruit health center management staff or are unable to support a full time person in that role. These individuals may be considered for inclusion on Lines 30a1, 30a2, 30a3, and 30a4.

Persons (Columns A and C)

Include all individuals who are working on the last day of the year or who are current employees/contractors who have that day off, but are scheduled to return on a specific day. (In other words, include someone who has the day off or who is on vacation or sick leave, but do not include individuals who may be used again in the future, but are not regular staff.) Unlike Table 5, Table 5A is a census of staff as of the last work day of the year (i.e., December 31). Also, unlike Table 5, count each individual that serves in one of the roles identified on Table 5A as 1 person. FTEs are not to be considered; Columns A and C only permit the entry of whole numbers. In order to be included in the count of health center staff and clinicians, an individual must meet one or more of the following criteria: •

Be employed full time

Be employed part time on a regular basis with a regular schedule

Be an NHSC clinician who is assigned to the health center

Be contracted on a regular basis with a regular schedule

Be an on-call, locum, resident, or volunteer provider who has worked a regular schedule for at least 6 months

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Do not count individuals who may work many days, but do not work a regular schedule, such as a locum or on-call provider who is called in any time one of the many physicians on staff are sick.

Total Months (Columns B and D)

The number of months reported for each person being included on Table 5A, is equal to the number of continuous months (rounded up to the next whole number) that that person has been in his/her current position. For example: •

Persons who have been continuously employed (contracted for) in their current position, regardless of whether or not the census day is a regular work day: Report the number of months since they were hired.

Persons who have been employed more than once and whose employment was terminated between the two (or more) periods: Report the number of months since they were most recently hired.

Persons who have served multiple positions in a health center (e.g., a long term physician who was recently promoted to medical director): Report the number of months since they began the position they are being counted for.

Persons who are currently working in two or more positions (e.g., a pediatrician/medical director or CEO/CFO): Report the number of continuous months they have been holding each position. (So it might be 50 months as pediatrician and 9 months as medical director.)

Instructions for Columns Full and Part Time Staff, Column A

Table 5A, Column A provides information on the number of full and part time staff as defined above who work in selected positions within the scope of the project for all of the programs covered by the UDS. All staff reported on a given line on Table 5A will have been reported on the same line on Table 5. Count each staff person working in a given position who qualifies under the definitions above as 1 staff person. For example: •

A full time physician who was employed on the census date is counted as 1 person.

Two half time physicians who were employed on the census date (regardless of whether or not they actually worked that day) are counted as 2 persons.

A part time physician who works 2 months every summer during the migrant season, but was not present on the census date is counted as 1 person.

A full time physician who worked for the center for ages, but resigned prior to the census date is not counted at all.

A physician on pregnancy leave who has been out for 8 weeks but intends to return after the leave is over is counted as 1 person even though she was not present on the census date.

Loc*ms, On-call, and Other Service Providers and Consultants, Column C

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reported on a given line on Table 5A will have been reported on the same line on Table 5, though it is possible that some part time FTEs counted on Table 5 will not be included in the count on Table 5A. Count each staff person working in a given position who qualifies under the definitions above as 1 staff person.

Months, Columns B and D

Report the total number of continuous months with the health center for those persons identified in column A or C, for example: •

A full time physician who has worked since 1/1/2012 is credited with 48 months. (4 full years × 12 months)

Two half time physicians who began working on 7/1/2001 are credited with a total of 348 months. (14.5 years × 2 staff × 12 months)

A part time physician who has worked every summer during the migrant season since 7/1/2004, is credited with 138 months. (11.5 years × 12 months)

A cardiologist who has worked the first and third Wednesday of every month since 1/18/2012 is credited with 48 months.

A full time physician who worked for the center for many years, but resigned prior to the census date is not reported on this table.

A physician who has been (and remains) a pediatrician since 1/1/2012 and medical director since 7/1/2015 is credited with 48 months as a pediatrician and 6 months as a medical director.

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Questions and Answers for Table 5A 1. Are there changes to this table? No. 2. Are we to reflect FTE or whole numbers to reporting persons on Table 5A? Unlike Table 5 which reports staff FTEs, Table 5A reports persons in Columns A and C, based on their year-end employment contract or arrangement. Regardless of whether the person works a full or part time schedule or works for the full year or part year, report them as 1 person. 3. If someone fills two roles at the health center, how do I choose which line to report them on? If an individual serves multiple roles for the health center (at the end of the year), report them as 1 person on each of the corresponding lines. Also report the months of tenure in each position. 4. We received our health center funding/designation status in 2015, should we count months of tenure as of the date of funding/designation? Months of tenure are not limited to the start of funding or designation, or even to the calendar year. Months of tenure are to be counted from the start of an individual’s employment for the health center in their current (year-end) position. Thus a family physician who was first employed at the health center on January 15, 2011 will be counted as having 60 months tenure, even though funding or designation occurred in 2015. If there was a gap in employment, you would exclude the time prior to the gap. Months should be rounded up to the nearest whole number for reporting purposes. 5. If we reported staff on Table 5 for a particular line, should we report this same staff on the corresponding line of Table 5A? Not necessarily. While all staff included on Table 5A will also be reported on Table 5, the reverse is not always true. In cases where an individual was no longer employed as of the last day of the reporting year, you would not count them on Table 5A. For example, if the chief executive officer left your organization in November, you would not report them on Table 5A since they were not there at the end of the year, but you would report the calculated FTE on Table 5.

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Table 5A: Tenure for Health Center Staff Reporting Period: January 1, 2015 through December 31, 2015

Line

Health Center Staff

Full and Part Time Total Persons Months (a) (b)

Locum, On-Call, etc. Total Persons Months (c) (d)

1

Family Physicians

2

General Practitioners

3

Internists

4

Obstetrician/Gynecologists

5

Pediatricians

7

Other Specialty Physicians

9a

Nurse Practitioners

9b

Physician Assistants

10

Certified Nurse Midwives

11

Nurses

16

Dentists

17

Dental Hygienists

20a

Psychiatrists

20a1

Licensed Clinical Psychologists

20a2

Licensed Clinical Social Workers

20b

Other Licensed Mental Health Providers

22a

Ophthalmologist

22b

Optometrist

30a1

Chief Executive Officer

30a2

Chief Medical Officer

30a3

Chief Financial Officer

30a4

Chief Information Officer

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Instructions for Table 6A: Selected Diagnoses and Services Rendered Beginning with 2012, data reported on Table 6A include all visits with the designated diagnoses and all patients who received these diagnoses, regardless of whether it was a primary diagnosis, a secondary diagnosis, a tertiary diagnosis, or any other level. The Centers for Medicare and Medicaid Services (CMS) is requiring entities that bill Medicare to cease using ICD-9 codes and begin using ICD-10 codes on October 1, 2015. Because data reported on Table 6A is reported for the entire calendar year, it will require the use of both ICD-9 and ICD-10 to report 2015 data. Health centers should refer to the table for both ICD-9 and ICD-10 codes used for the specified diagnosis. The ICD-10 codes are notably different from the ICD-9 codes and it is important that health centers use the appropriate coding based on the service and where multiple codes may be indicated on a patient’s chart, special attention is required to ensure that patients and their visits are unduplicated. Please note the ICD-10 transition will not affect CPT coding which is used to describe the services reported on this table. This table reports on two separate sets of data: selected diagnoses and selected services rendered. It is designed to provide this information using data maintained for billing purposes and/or in electronic health records. As a subset of diagnoses and services, Table 6A is not expected to reflect the full range of diagnoses and services rendered by a health center. The diagnoses and services selected represent those that are prevalent among Health Center Program patients or which are generally regarded as sentinel indicators of access to primary care or are of special interest to HRSA. Diagnoses reported on this table are those made by a medical, dental, mental health, substance abuse, or vision provider, only. Thus, if a case manager or health educator sees a diabetic patient, the visit is not to be reported on Table 6A. But if a physician shows the primary diagnosis as hypertension and the secondary diagnosis as diabetes, the visit and the patient are both recorded on both the line for hypertension and the line for diabetes. The table is included in both the Universal report and Grant reports. •

The Universal Report: Column A provides data on all visits where each of the specified diagnostic or service codes was reported. Column B reports all individuals who had at least one visit where the specified diagnostic or service category was reported. The report includes all applicable diagnoses coded and services provided within the scope of any and all health center program-supported projects included in the UDS.

The Grant Report: The Grant report provides the same data for those visits provided to individuals served within the scope of the specific grant program, regardless of the source of the funding which paid for the visit or service.

Because Grant reports are sub-sets of the Universal report, no cell on a grant report may exceed the comparable cell of the Universal report. Selected Diagnoses: Lines 1 through 20d present the name and applicable ICD-9-CM and ICD-10-CM codes for the diagnosis or diagnostic range/group. Wherever possible, diagnoses have been grouped into code ranges. Where a range of ICD-9-CM or ICD-10-CM codes is shown, health centers should report on all visits where the provider assigned diagnostic code is included in the range/group. All diagnoses reported for the visit are reported on Table 6A if they are included in the codes provided.

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The ICD-10 codes are notably different from the ICD-9 codes and it is important that health centers use the appropriate coding based on the service and where multiple codes may be indicated on a patient’s chart, special attention is required to ensure that patients and their visits are unduplicated. This manual includes the necessary codes for reporting using data drawn from both ICD-9 and ICD-10 codes. Additional information is available on the conversion process at https://www.cms.gov/ICD10/11b1_2011_ICD10CM_and_GEMs.asp. Selected Tests/Screenings/Preventive Services: Lines 21 through 26d present the name and applicable ICD-9-CM and ICD-10 diagnostic and/or CPT procedure codes for selected tests, screenings, and preventive services which are particularly important to the populations served or of particular interest to HRSA and are services performed by the health center or by contracted paid referral. On several lines both CPT codes and ICD-9 and ICD-10 codes are provided. Health centers may use either the CPT codes or the ICD-9 and ICD-10 codes for any specific visit, but not both. All visits meeting the selection criteria and definitions are reported. A reported service may be in addition to another service, and may be in addition to a reported diagnosis or may stem from a visit where there was no UDS-reportable diagnosis code. Note: ICD-9 “V-Codes” and comparable ICD-10 codes for mammography and Pap tests are listed to ensure capture of procedures which are done by the health center, but coded with a different CPT code for State reimbursem*nt under Title X or BCCCP. In some instances payers (especially governmental payers) ask health centers to use different codes for services which are included in the UDS. In these instances, health centers should add these codes to the published list for reporting purposes. Health centers must actually perform the test in their labs or collect the sample and transfer it to a reference lab for the test which is paid for by third party payer to be counted. Do not report referrals or orders for tests or procedures, such as mammograms, x-rays, or tomography, which are not performed by or paid for by the health center. (For example, referral of a woman to the County Health Department for a mammogram would not be counted.) The only exception to this is lab tests ordered by a health center, but paid for by a third party payer including Medicare and Medicaid are to be included, as are mammograms performed by a health center, but read by an outside radiologist who then bills a third party. Selected Dental Services: 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 16–17 on Table 5 or by an inscope 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. Note that fluoride treatments or varnishes which are applied outside of a comprehensive treatment plan, especially when provided as part of a community service at schools, are not to be counted nor does this activity generate a visit reported on Table 5. Dental services reported on Table 6A must be provided directly by a licensed dental provider. Please note: Only services which are provided at a “countable” visit are reported on Table 6A; included in these would be services “attendant to” a countable visit. Thus, if a provider asks that a patient come back 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. Another person, who is not a clinic patient and who comes in just for a flu shot during a health-center run flu clinic and without a specific referral from a prior visit, would not have the interaction reported on Table 6A. Multiple Entities Involved with Services: Care must be taken when multiple entities are involved with a service. In general: 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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If the health center provider orders and performs the service, the service is counted. For example, a rapid HbA1c test ordered by a physician and performed in the clinic lab is counted.

If children are routinely referred to the County Health Department for vaccinations, the vaccinations performed by the Health Department are not reported.

If the health center provider orders a test (e.g., HIV tests), the sample is collected at the health center, and then sent to a reference lab for processing, the test is counted, regardless of whether the test is paid for by the patient, the patient’s insurance company 4 or the health center.

If a provider asks the patient to get a test not performed by the health center from a third party provider which sends the results back to the provider to be acted on and bills the health center which pays for it, that test is counted. Thus, a health center with a contract to pay for mammograms performed by a third party provider is counted.

If a provider asks the patient to get a test not performed by the health center from a third party provider which may send the results back to the provider to be acted on but which does not bill the health center, that test is not counted. Thus a health center which sends a patient to the County Health Department for a mammogram which the County will follow up with the patient directly is not counted or reported.

If a provider sends a patient to a third party for a service not provided by the health center, such as sending a patient for an HIV test to a Ryan White program, where the receiving entity performs the service and follows up with the patient, the health center does not count that service.

Number of Visits, Column A Lines 1–20d: Visits by Selected Diagnoses Report the total number of visits during the reporting period where the indicated diagnosis is listed in the EHR or visit/billing record. If a visit has a diagnosis which is among the many diagnoses not listed on Table 6A, it is not reported. All visits are entered into an EHR or a clinic practice management/billing systems, with one diagnosis listed as primary and successive diagnoses listed as secondary, tertiary, etc. Each diagnosis made at a visit may be counted on Lines 1–20d regardless of the number of diagnoses listed for the visit. Thus, a patient visit with a primary diagnosis of hypertension and a secondary diagnosis of diabetes will be counted once on Line 11 for hypertension and once on Line 9 for diabetes. Lines 21–34: Visits by Selected Tests/Screenings/Preventive and Dental Services Report the total number of visits at which one or more of the listed diagnostic tests, screenings, and/or preventive services were provided. Note that codes for these services may either be diagnostic (ICD-9 or ICD-10) codes or procedure (ADA or CPT-4) codes. During one visit, more than one test, screening, or preventive service may be provided. If these procedures or tests are on different lines, each would be counted. If they are on the same line, only one would be counted. For example:

4

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 their health center.

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One visit may involve more than one of the identified services in which case each should be reported. For example, if during a visit both a Pap test and an HIV test were provided then a visit would be reported on both Lines 21 (HIV Test) and 23 (Pap test).

If a patient receives multiple immunizations at one visit, only one visit should be reported on Line 24.

Services are reported in addition to diagnoses. A hypertensive patient who also receives an HIV test would be counted once on the hypertension Line 11 and once on the HIV test Line 21.

Services are also reported where no diagnosis is reported. A patient who comes in for intense headaches who also gets a flu shot would be counted on the flu shot line (Line 24a), but not on any diagnostic line.

If a patient had more than one tooth filled during a visit, only one visit for restorative services (Line 32) should be reported, not one per tooth.

Number of Patients, Column B Lines 1–20d: Patients by Diagnosis For Column B, report each individual who had one or more visits during the year which was reported in the corresponding Column A. A patient is counted once and only once on any given line, regardless of the number of visits made for that specific diagnosis or family of diagnoses. Any patient may have visits with multiple diagnoses, for example, hypertension and diabetes. In this case, the patient would be reported in column B once (and only once) for each diagnosis used during the year. Thus, a patient with one or more visits with a diagnosis of hypertension and one or more visits with a diagnosis of diabetes is counted once and only once as a patient on both of Lines 9 and 11, regardless of how many times they were seen. Where multiple codes may be indicated on a patient’s chart, special attention is required to ensure that patients are unduplicated by diagnosis. This may be a significant issue in 2015’s data where a patient seen for multiple visits in 2015 is likely to have an ICD-9 diagnosis and an ICD-10 diagnosis for the same condition. Since both ICD-9 and ICD-10 diagnosis will be reported on the same UDS Table 6A line, the patient must be counted only once in Column B. Lines 21–26d: Patients by Selected Diagnostic Tests/Screening/Preventive Services Report patients who have had at least one visit during the reporting period where the selected diagnostic tests, screenings, and/or preventive services listed on Lines 21–26d was provided. Patients may be counted for more than one service during a single visit. Thus, 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 in Column B. Regardless of the number of times a patient receives a given service, s/he is counted once and only once on that line in Column B. 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. Where multiple codes may be indicated on a patient’s chart, special attention is required to ensure that patients are unduplicated by service. Lines 27–34: Patients by Selected Dental Services Report patients who have had at least one visit with a dental professional during the reporting period for each of the selected dental services listed on Lines 27-34. (Services provided by persons other than a dentist or a dental hygienist may not be reported here.) If a patient had two 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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teeth repaired and sealants applied during one visit, this patient would be counted once (only) on both Lines 30 and 32 in Column B.

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Questions and Answers for Table 6A 1. Are there changes to this table? Yes. The Centers for Medicare and Medicaid Services (CMS) is requiring entities that bill Medicare to cease using ICD-9 codes and begin using ICD-10 codes on October 1, 2015. Because data reported on Table 6A is reported for the entire calendar year, it will require the use of both ICD-9 and ICD-10 to report 2015 data. Health centers should refer to the table for both ICD-9 and ICD-10 codes used for the specified diagnosis. The ICD-10 codes are notably different from the ICD-9 codes and it is important that health centers use the appropriate coding based on the service and where multiple codes may be indicated on a patient’s chart, special attention is required to ensure that patients and their visits are unduplicated.. Please note the ICD-10 transition will not affect CPT coding which is used to describe the services reported on this table. In addition, line 1-2a, First time diagnosis of HIV, has been removed from this table and is now reported only on table 6B, line 20. 2. If a case manager or health educator serves a patient who is, for example, a diabetic, we often show that diagnostic code for the visit. Should this be reported on Table 6A? No. Report only visits with medical, dental, mental health, substance abuse, and vision providers on Table 6A. Note that diagnoses are generally limited to those professionals in the specific area of expertise. 3. The instructions 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? Services given at health fairs are not counted, regardless of who provides the service or the level of documentation that is done. If a service is provided as a result of a prescription or plan from an earlier visit that was counted it is counted. For example, if a provider asked a woman to come back in 4 months for a mammogram that is done at the health center, it would be counted. But if the service is a self-referral where no clinical visit is necessary or provided (such as an HIV test at a health fair or a senior citizen coming in for a flu shot) it is not counted. 4. Some diagnostic and/or procedure codes in my system are different from the codes listed. What do I 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 provides examples of problems and solutions. Line # 1 23

Problem HIV diagnoses are kept confidential and alternative diagnostic codes are used Pap tests are charged to State BCCCP program using a special code

Potential Solution Include the alternative codes used at your center on these lines as well Add these special codes to the other codes listed

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Line # 26

Problem Well child visits are charged to the State EPSDT program using a special code (often starting with W, X, Y, or Z)

Potential Solution Add these special codes to the other codes listed and count all such visits as well. Do not count EPSDT follow-up visits in this category.

5. The instructions specifically say that the source of information for Table 6A is “billing systems or EHRs.” There are some services for which I do not bill and/or for which there are no visits in my system. What do I do? Referrals for which you do not pay (e.g., sending women to the County Health Department for a mammogram) are not to be counted. While health centers are only required to report data derived from billing systems or EHRs, the reported data may understate services in the circ*mstances described below. In today’s Electronic Health Records, virtually all of these diagnoses and/or services should be captured in one or another of the templates available. In order to more accurately reflect your level of service, health centers may also use other codes in their system to enable the tracking. For example, if a child is given a vaccination which the clinic does not charge for because they received it free from the Vaccine for Children program, the regular code with an extension may be used to indicate that it is not to be billed or the code may have a zero charge attached to it. Line #

Problem

21

HIV tests 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.

Multiple

Tests (such as HIV tests, Pap tests, etc.) are ordered and collected by us and we send it to a reference lab for processing, but the lab bills Medicaid or Medicare directly.

22

Mammograms are paid for, but are conducted by a contractor and do not show in the billing system for individual patients.

23

Pap tests are processed and paid for by the State and do not show on the visit form or in the billing system.

24

Flu shots and other vaccinations are not counted because the vaccines are obtained at no cost to the center.

Potential Solution Preferred: Use the correct code, but show a zero charge. Alternatively, you may use the correct code with a “.52” extension to indicate you did not do the complete test. Preferred: Use the correct code, but show a zero charge. Alternatively, you may use the correct code with a “.52” extension which indicates that not all components of the service was provided by the health center. Preferred: Use the correct code, but show 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 show a zero charge. Alternative: Use the correct code with a “.52” extension to indicate you did not do the technical component of the test. Preferred: Use the correct code, but show a zero charge. Alternative: Use the correct code with a “.52” extension to indicate you did not do the technical component of the test.

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Line # 25

Problem

Potential Solution

Contraceptive management is funded under Title X or a State family planning program and does not have a V-25 or Z30 diagnosis attached to it.

Preferred: Add a “dummy code” you can map to the V-25 code. Alternative: Code with both the V-25/Z30 and the State mandated code but suppress printing of the V-25/Z30 code. Take care not to count the same visit twice.

6. Are health centers required to report all diagnoses and services rendered during a visit? Yes. Health centers are required to document and report all diagnoses, not just primary diagnosis, and services rendered during all UDS-countable visits. It is important that health centers appropriately document the breadth of comprehensive services delivered during each visit, including documentation of behavioral health services (i.e., SBIRT and/or treatment of counseling for mental health and/or substance use disorders) provided during a medical visit.

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Table 6A: Selected Diagnoses and Services Rendered Reporting Period: January 1, 2015 through December 31, 2015

Table 6A: Selected Diagnoses Lin e

Selected Infectiou s and Parasitic Disease

Diagnostic Category

Selected Infectious and Parasitic Diseases

12.

Symptomatic / Asymptomatic HIV

3.

Tuberculosis

4.

4a.

4b. Selected Diseases of the Respirat ory System

Sexually transmitted infections

Hepatitis B

Hepatitis C

Selected Diseases of the Respiratory System

5.

Asthma

6.

Chronic obstructive pulmonary diseases

Selected Other Medical Conditio ns

7.

Selected Other Medical Conditions

Abnormal breast findings, female

Applicable ICD-9-CM Code Selected Infectious and Parasitic Diseases

Abnormal cervical findings

Number of Visits by Diagnosis regardless of primacy (a)

Number of Patients with Diagnosis (b)

Selected Infectious and Parasitic Diseases

Selected Infectious and Parasitic Diseases

Selected Infectious and Parasitic Diseases

042 , 079.53, V08

B20, B97.35, O98.7, Z21

010.xx – 018.xx

A15- thru A19-

A50- thru A64(Exclude A63.0), M02.3-, N34.1

090.xx – 099.xx

070.20, 070.22, 070.30, 070.32, V02.61

B16.0-B16.2, B16.9, B17.0, B18.0, B18.1, B19.10, B19.11, Z22.51

B17.10, B17.11, B18.2, B19.20, B19.21, Z22.52

Selected Diseases of the Respiratory System

Selected Diseases of the Respiratory System

Selected Diseases of the Respiratory System

070.41, 070.44, 070.51, 070.54, 070.70, 070.71, V02.62 Selected Diseases of the Respiratory System

493.xx

J45-

490.xx – 492.xx

J40- thru J44and J47-

Selected Other Medical Conditions

Selected Other Medical Conditions

C50.01-, C50.11-, C50.21-, C50.31-, C50.41-, C50.51-, C50.61-, C50.71-, C50.81-, C50.91-, C79.81, D48.6-, R92-

C53-, C79.82, D06-, R87.61-, R87.810, R87.820

Selected Other Medical Conditions

174.xx; 198.81; 233.0x; 238.3 793.8x

180.xx; 198.82; 8.

Applicable ICD-10-CM Code

233.1x; 795.0x

Selected Other Medical Conditions

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Lin e

9.

Diagnostic Category

Diabetes mellitus

Applicable ICD-9-CM Code

Number of Visits by Diagnosis regardless of primacy (a)

Number of Patients with Diagnosis (b)

E10- thru E13-, O24- (Exclude O24.41-)

I01-, I02(exclude I02.9), I20- thru I25, I26- thru I28-, I30- thru I52-

401.xx – 405.xx;

I10- thru I15-

692.xx

L23- thru L25-, L30- (Exclude L30.1, L30.3, L30.4, L30.5), L55- thru L59 (Exclude L57.0 thru L57.4)

276.5x

E86-

991.xx – 992.xx

T33.XXXA, T34.XXXA, T67.XXXA, T68.XXXA, T69.XXXA E66-, Z68(Excluding Z68.1, Z68.2024, Z68.51. Z68.52)

Selected Childhood Conditions (limited to ages 0 thru 17)

Selected Childhood Conditions (limited to ages 0 thru 17)

250.xx; 648.0x

391.xx – 392.0x 10.

Heart disease (selected)

11.

Hypertension

12.

Contact dermatitis and other eczema

13.

Dehydration

14.

14 a. Selected Childhoo d Conditio ns (limited to ages 0 thru 17)

15.

16.

Exposure to heat or cold

410.xx – 429.xx

ICD-9 : 278.0 – 278.03 or V85.xx Overweight and obesity

Selected Childhood Conditions (limited to ages 0 thru 17) Otitis media and Eustachian tube disorders

Selected perinatal medical conditions

excluding V85.0, V85.1, V85.51 V85.52 Selected Childhood Conditions (limited to ages 0 thru 17)

Applicable ICD-10-CM Code

Selected Childhood Conditions (limited to ages 0 thru 17)

381.xx – 382.xx

H65- thru H69-

770.xx; 771.xx; 773.xx; 774.xx – 779.xx (excluding 779.3x)

A33-, P20- thru P29- (exclude P22.0, P29.3); P35- thru P96(exclude P50-, P51-, P52-, P54-, P91.6-, P92-, P96.81), R78.81, R78.89

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Lin e

Diagnostic Category

17.

Lack of expected normal physiological development (such as delayed milestone; failure to gain weight; failure to thrive); Nutritional deficiencies in children only. Does not include sexual or mental development.

Selected Mental Health and Substanc e Abuse Conditio ns

Selected Mental Health and Substance Abuse Conditions

18.

Alcohol related disorders

19.

Other substance related disorders (excluding tobacco use disorders)

19 a.

Tobacco use disorder

20 a.

Depression and other mood disorders

20 b.

Anxiety disorders including PTSD

20 c.

Attention deficit and disruptive behavior disorders

20 d.

Other mental disorders, excluding drug or alcohol dependence

Applicable ICD-9-CM Code

Applicable ICD-10-CM Code

Number of Visits by Diagnosis regardless of primacy (a)

Number of Patients with Diagnosis (b)

E40-E46, E50thru E63(exclude E64-), P92-, R62(exclude R62.7), R63.2, R63.3

Selected Mental Health and Substance Abuse Conditions

Selected Mental Health and Substance Abuse Conditions

Selected Mental Health and Substance Abuse Conditions

Selected Mental Health and Substance Abuse Conditions

291.xx, 303.xx; 305.0x

F10-, G62.1

292.1x – 292.8x 292.9, 304.xx, 305.2x – 305.9x 357.6x, 648.3x

F11- thru F19(Exclude F17-), G62.0, O99.32-

305.1

F17-

296.xx, 300.4

F30- thru F39-

300.0x, 300.2x, 300.3, 308.3,309.81

F40- thru F42F43.0, F43.1-

312.8x, 312.9x, 313.81, 314.xx

F90- thru F91-

290.xx

F01- thru F09-, F20- thru F29-, F43- thru F48(exclude F43.1), F50- thru F59(exclude F55-), F60- thru F99(exclude F84.2, F90-, F91-, F98), R45.1, R45.2, R45.5, R45.6, R45.7, R45.81, R45.82, R48.0

260.xx – 269.xx (excluding 268.2); 779.3x; 783.3x – 783.4x;

357.5x

301.13, 311.xx

293.xx – 302.xx (excluding 296.xx, 300.0x, 300.2x, 300.3, 300.4, 301.13); 306.xx - 319.xx (excluding 307.xx, 308.3, 309.81, 311.xx, 312.8x, 312.9x,313.81,314.xx)

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Table 6A: Selected Services Rendered Line

Service Category Sel ected Diag nos tic Tests /Scr eeni ng/Pr eventi ve Ser vic es

21.

Selected Diagnostic Tests/ Screening/Preventive Services

HIV test

Applicable ICD-9-CM or CPT4/II Code Selected Diagnostic Tests/Screening/Preventive Services

Applicable ICD-10-CM Code or CPT-4/II Code

Number of Visits (a)

Number of Patients (b)

Selected Diagnostic Tests/Screening/Preventive Services

Selected Diagnostic Tests/Screening/Preventive Services

Selected Diagnostic Tests/Screening/Preventive Services

CPT-4: 86689;

CPT-4: 86689;

86701-86703;

86701-86703;

87390-87391

87390-87391

21 a.

CPT-4: 86704, 86706, 87515-17

CPT-4: 86704, 86706, 8751517

Hepatitis B test

21 b.

Hepatitis C test

CPT-4: 86803-04, 87520-22

CPT-4: 8680304, 87520-22

CPT-4: 77052, 77057

CPT-4: 77052, 77057

22.

Mammogram

OR ICD-9: V76.11; V76.12

23.

Pap test

CPT-4: 88141-88155; 88164-88167, 8817488175 OR ICD-9: V72.3; V72.31, V72.32; V76.2

24.

Selected Immunizations: Hepatitis A, Hemophilus Influenza B (HiB), Pneumococcal, Diphtheria, Tetanus, Pertussis (DTaP) (DTP) (DT), Mumps, Measles, Rubella, Poliovirus, Varicella, Hepatitis B Child)

24 a.

Seasonal Flu vaccine

25.

Contraceptive management

CPT-4: 90633-90634, 90645 – 90648; 90670; 90696 – 90702; 90704 – 90716; 90718 - 90723; 90743 – 90744; 90748

OR ICD-10: Z12.31 CPT-4: 8814188155; 8816488167, 8817488175 OR ICD-10: Z01.41-, Z01.42, Z12.4 CPT-4: 9063390634, 90645 – 90648; 90670; 90696 – 90702; 90704 – 90716; 90718 - 90723; 90743 – 90744; 90748

CPT-4: 90654 – 90662, 90672-90673, 90685-90688

CPT-4: 90654 – 90662, 90672-90673, 90685-90688

ICD-9: V25.xx

ICD-10: Z30-

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Line

Service Category

26.

26 a. 26 b.

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)

26 c.

Smoke and tobacco use cessation counseling

26 d.

Comprehensive and intermediate eye exams

Line

Service Category Selected Dent al Services

Selected Dental Services 27.

I. Emergency Services

Applicable ICD-9-CM or CPT4/II Code

Applicable ICD-10-CM Code or CPT-4/II Code

CPT-4: 9939199393;

CPT-4: 99391-99393; 99381-99383;

Number of Patients (b)

99381-99383;

CPT-4: 83655

CPT-4: 83655

CPT-4: 99408-99409

CPT-4: 9940899409 CPT-4: 99406 and 99407;

CPT-4: 99406 and 99407; HCPCS: S9075, CPTII: 4000F, 4001F

HCPCS: S9075, CPT-II: 4000F, 4001F

CPT-4: 92002, 92004, 92012, 92014

CPT-4: 92002, 92004, 92012, 92014

Applicable ADA Code

Applicable ADA Code

Selected Dental Services

Number of Visits (a)

Selected Dental Services

Number of Visits (a)

Number of Patients (b)

Selected Dental Services

Selected Dental Services

ADA : D9110

ADA : D9110

ADA : D0120, D0140, DO145, D0150, D0160, D0170, D0171, D0180

28.

II. Oral Exams

ADA : D0120, D0140, DO145, D0150, D0160, D0170, D0171, D0180

29.

Prophylaxis – adult or child

ADA : D1110, D1120,

ADA : D1110, D1120,

30.

Sealants

ADA : D1351

ADA : D1351

31.

Fluoride treatment – adult or child

ADA :, D1206, D1208

ADA :, D1206, D1208

32.

III. Restorative Services

ADA : D21xx – D29xx

ADA : D21xx – D29xx

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Line

Service Category

Applicable ADA Code

33.

IV. Oral Surgery (extractions and other surgical procedures)

ADA : D7111, D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7251, D7260, D7261, D7270, D7272, D7280, D7290-D7294

34.

V. Rehabilitative services (Endo, Perio, Prostho, Ortho)

ADA : D3xxx, D4xxx, D5xxx , D6xxx, D8xxx

Applicable ADA Code

Number of Visits (a)

Number of Patients (b)

ADA : D7111, D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7251, D7260, D7261, D7270, D7272, D7280, D7290D7294

ADA : D3xxx, D4xxx, D5xxx , D6xxx, D8xxx

Sources of Codes: • International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), Volumes 1 and 2, 2014. American Academy of Professional Coders • International Classification of Diseases, 2014, Complete Draft Code Set (ICD-10-CM). American Academy of Professional Coders • Current Procedural Terminology, (CPT) 2014. American Medical Association. • Current Dental Terminology, (CDT) 2015 – Dental Procedure Codes. American Dental Association (ADA). NOTE: x or - in a code denotes any number including the absence of a number in that place. ICD-10 codes all have at least 4-digits.

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Instructions for Table 6B: Quality of Care Measures Table 6B is included only in the Universal report. It is completed by all health centers. Beginning with CY 2015 reporting, additional reporting changes have been made to this table and are outlined in the instructions below. This table reports data on selected quality of care measures. BPHC first implemented these measures in 2008, and has been updating and adding to them since then. BPHC will continue to revise and expand these measures consistent with the National Quality Strategy and other national quality initiatives. These quality of care measures are “process measures” which means that they document services which have been shown to be correlated with, and serve as a proxy for, good long term health outcomes. We know that individuals who receive timely routine and preventive care are more likely to have improved health status. Thus, by increasing the proportion of health center patients who receive timely preventive care and routine acute and chronic care, we can expect improved health status of the patient population in the future. Specifically:

PLEASE NOTE IMPORTANT CLARIFICATION FOR 2015 In order to streamline the process for reporting on clinical quality measures, and encourage the use of electronic health records to report on the full universe of patients for the UDS clinical performance measures in Table 6B and Table 7, health centers may use an EHR in lieu of a chart sample if at least 80% of all health center patient records are included in the EHR for any given measure. •

Trimester of entry into prenatal care: If women enter care in their first trimester, then the probability of adverse birth outcome will be reduced.

Childhood immunization: If children receive their vaccinations in a timely fashion, then they will be less likely to contract vaccine preventable diseases or to suffer from the sequela of these diseases.

Cervical cancer screening: If women receive Pap tests as recommended, then early detection and treatment of abnormalities can occur and they will be less likely to suffer adverse outcomes from HPV infection and cervical cancer.

Weight assessment and counseling for children and adolescents: If clinicians ensure that their patients’ body mass indicator (BMI) percentile is recorded, and if patients (and parents) are counseled on nutrition and physical activity (regardless of the patient’s weight), then the likelihood of obesity and its sequela will be reduced.

Adult Weight screening and follow-up: If clinicians routinely calculate and record the BMI for their adult patients, and if they identify patients with weight problems and develop a follow-up plan for overweight and underweight patients, then the likelihood of the debilitating sequela of serious weight problems can be reduced.

Tobacco use screening and cessation intervention: If patients are routinely queried about their tobacco use and are provided with effective cessation counseling and pharmacologic intervention if they are tobacco users, then patients will be more likely to quit using tobacco and will therefore have a lower risk of cancer, asthma, emphysema, and other tobacco related illnesses.

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Asthma pharmacologic therapy: If patients identified with persistent asthma are provided with appropriate pharmacological intervention, then they will be less likely to have asthma attacks, they will require fewer emergency room visits, and be less likely to develop complications related to asthma including death.

Coronary artery disease (CAD): Lipid therapy: If clinicians ensure that patients with established coronary artery disease and high lipid levels receive lipid lowering therapy, then the likelihood of CAD related clinical events will be reduced.

Ischemic Vascular Disease (IVD): Aspirin or antithrombotic therapy: If clinicians ensure that patients with established ischemic vascular disease (IVD) use aspirin or another antithrombotic drug, then the likelihood of myocardial infarctions, and other vascular events can be reduced.

Colorectal cancer screening: If patients 50 to 75 years old receive appropriate colorectal screening, then early intervention is possible and premature death can be averted.

HIV linkage to care: If patients found to be HIV positive are seen for follow-up care within 90 days of initial HIV diagnosis, then the probability of HIV-related complications and transmission of disease are reduced.

Patients screened for depression and follow-up: If patients age 12 and older are routinely screened for depression and are provided with a follow-up plan if they are screened as positive, then they will be more likely to receive needed treatment and less likely to suffer from the sequela of depression.

Dental sealants: If patients age 6 through 9 with moderate to high risk for caries are provided sealants on first permanent molars, then they will be less likely to experience dental decay.

While the selected quality of care measures give a good overall description of the overall quality of primary care being provided at the center, it is clear that this is a subset of possible quality of care measures. The clinical quality measures described in this manual must be reported by all health centers. However, individual health centers may use additional measures, including modified versions of these measures in their grant applications, or for other internal purposes at their discretion. Additionally, the use of official versions of vocabulary value sets as contained in the Value Set Authority Center (VSAC) is encouraged for organizations capable of appropriately using this resource as defined below to support the data reporting of these quality of care measures.

Sections A and B: Demographic Characteristics of Prenatal Care Patients

All health centers must report on all prenatal care patients who are either provided direct care or referred for care. All health centers must 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. Section A: Age of Prenatal Care Patients (Lines 1–6) Report the total number of patients who received or were referred for prenatal care services at any time during the reporting period by age group. Be sure to include all women receiving any

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prenatal care during the reporting year, including the delivery of her child, regardless of when that care was initiated, including women who: •

Began or were referred for prenatal care during the previous reporting period and continued into this reporting period

Began or were referred for care and delivered during the reporting year

Began or were referred for their care in this reporting period, but will not/did not deliver until the next year

“Total prenatal care patients” includes patients who: •

Receive all their prenatal care from the health center

Were referred by the health center for all their prenatal care or began prenatal care with another provider but transferred to the health center

Began prenatal care with the health center, but were transferred to another provider at some point during their prenatal care

Were provided with all their prenatal care by a health center provider, but were delivered by another provider

To determine the appropriate age group, use the woman’s age on June 30, of the reporting period. As many as half of all patients reported will usually have been reported in the prior year or will be reported in the next year. The total number of women reported in Section A on line 6 must be equal to the total women reported in section B – Trimester of Entry into Prenatal Care. Section B: Trimester of Entry into Prenatal Care (Lines 7–9) Performance Measure: The performance measure is “Proportion of prenatal care patients who entered treatment during their first trimester.” The measure itself, which is not dependent on which category of performance measurement achievement a woman might fall into, is calculated as follows: Numerator: Number of women beginning prenatal care at the health center or with the referred provider during their first trimester (Line 7, Columns A+B) Denominator: Total number of women seen for prenatal care during the year (Line 7 + Line 8 + Line 9, Columns A+B) Detailed Instructions for Clinical Measure All patients who received prenatal care, either directly or through a referral, including, but not limited to, the delivery of a child during the reporting period, are reported on Lines 7– 9. A number of criteria are used to identify how women are reported: •

The trimester is determined by the trimester of pregnancy that the woman was in when she began prenatal care either at one of the health center’s service delivery locations or with another provider including a referral provider.

A woman who begins her prenatal care with the health center or is referred by the health center to another provider is reported once and only once in Column A.

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A woman who begins her prenatal care on her own at another provider and then transfers to the health center, is counted once and only once in Column B, and is not counted in Column A.

Prenatal care is considered to have begun at the time the patient has her first visit with a physician or NP, PA, or CNM provider who initiates prenatal care with a complete prenatal exam. This visit is considered the “first visit” for UDS purposes. (Most women will have one or more interactions with the health center prior to that for their pregnancy test, other lab tests, dispensing vitamins and/or taking a health history. These interactions do not count as the start of prenatal care.)

In the event a woman is referred to another provider for care by a health center which does not have its own prenatal care program, the first visit is the visit at which they receive a complete prenatal exam from the referral provider. It is not when she first contacts the prenatal referral provider or when they do lab tests, or has psycho-social or nutritional assessments done.

A woman is counted only once regardless of the number of trimesters during which she receives care.

In those rare instances where a woman receives prenatal care services for two separate pregnancies in the same calendar year, she is to be counted twice. (This can occur if a woman delivers, for example, in January, and then becomes pregnant again in October.)

First Trimester (Line 7): Includes women who were prenatal 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 conception. 5 If the woman began prenatal care during the first trimester at the health center’s service delivery location or from a provider she was referred to by the health center, she is reported on Line 7 in Column A; if she received prenatal care from another provider during the first trimester before coming to the health center’s service delivery location, she is reported on Line 7 in Column B, regardless of when she begins care with the health center. Second Trimester (Line 8): Includes women who were prenatal 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 26th week after conception. If the woman began prenatal care during the second trimester at the health center’s service delivery location or from a provider she was referred to by the health center, she is reported on Line 8 in Column A; if she received prenatal care starting in the second trimester from another provider before coming to the health center’s service delivery location, she is reported on line 8 in Column B, regardless of when she begins care with the health center. Third Trimester (Line 9): Includes women who were prenatal care patients during the reporting period and whose “first visit” occurred when they were estimated to be 27

5

The end of the 13th week is used if health center calculates pregnancy as of conception. Obstetricians may count time from last reported menstrual period (LMP). Since this is two weeks earlier than conception, the first trimester would be considered up through 15 weeks post-LMP. The second trimester is through 28 weeks post-LMP. Trimester may be based on other data if conception or LMP data are not available.

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weeks or more after conception. If the woman began prenatal care during the third trimester at the health center’s service delivery location or from a provider she was referred to by the health center, she is reported on Line 9 in Column A; if she received prenatal care from another provider starting the third trimester before coming to the health center’s service delivery location, she is reported on Line 9 in Column B, regardless of when she begins care with the health center. (Note that it is highly unusual for the number in Column B to be very large or larger than that in Column A since it would require women to have begun care and then transferred 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 women who received prenatal care from the health center during the calendar year, and is equal to the number reported on Line 6. All prenatal women must be reported here, regardless of when they entered care (this year or last year), whether they were seen by the health center or a referral provider, or when they deliver (this year or next year).

Sections C through M: Other Quality of Care Measures

In these sections, health centers will report on the findings of their reviews of services provided to targeted populations of current medical patients (i.e., patients who had a medical visit at least once during the reporting period). Patients whose only visits were for dental, mental health, or something other than medical care are not included in the universe for these measures. These targeted populations, reported in Column A, are: Section C: Childhood Immunization (Line 10) Children with at least one medical visit during the reporting period, who had their third birthday during the reporting period, and who were first seen ever by the health center prior to their third birthday are reported on Line 10. For the purposes of this year’s reporting this includes children whose date of birth is between January 1, 2012, and December 31, 2012. Section D: Cervical Cancer Screening (Line 11) Women aged 21 through 64 with at least one medical visit during the reporting period, who were first seen by the health center at some point prior to their 65th birthday are reported on Line 11. For the purposes of this year’s reporting this includes women whose date of birth is between January 1, 1951, and December 31, 1991. (NOTE: This is the same measure that had been previously called “Women 24 through 64” for clarity purposes. No women aged 21, 22, or 23 in the reporting period should be included in the calculation of this measure.) Section E: Weight Assessment and Counseling for Children and Adolescents (Line 12) Children and adolescents aged 3 through 17 with at least one medical visit during the reporting period, who had their third birthday during or prior to the reporting period, and who were first seen ever by the health center prior to their 18th birthday are reported on Line 12. For the purposes of this year’s reporting this includes children and adolescents whose date of birth is between January 1, 1998, and December 31, 2012. Section F: Adult Weight Screening and Follow-up (Line 13) Adults age 18 or older, with at least one medical visit during the reporting period and seen after their 18th birthday are reported on Line 13. For the purposes of this year’s reporting this includes all medical patients born on or before December 31, 1997.

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Section G: Tobacco Use Screening and Cessation Intervention (Line 14a) Adults age 18 or older, seen after 18th birthday, with at least one medical visit during the reporting period, and with at least two medical visits ever, are reported on Line 14. For the purposes of this year’s reporting this includes all medical patients born on or before December 31, 1997. Section H: Asthma Pharmacologic Therapy (Line 16) Patients age 5 through 40 with at least one medical visit during the reporting period and at least two visits ever, with a diagnosis of mild, moderate or severe persistent asthma are reported on Line 16. For the purposes of this year’s reporting this includes all patients with persistent asthma born between January 1, 1975, and December 31, 2010. Section I: Coronary Artery Disease (CAD): Lipid Therapy (Line 17) Adults age 18 or older, seen after their 18th birthday, who had at least one medical visit during the reporting period, and with at least two medical visits ever, who have an active diagnosis of CAD including myocardial infarction (MI) or who have had cardiac surgery, are reported on Line 17. For the purposes of this year’s reporting this includes medical patients meeting the clinical profile who were born on or before December 31, 1997. Section J: Ischemic Vascular Disease (IVD): Aspirin or Antithrombotic Therapy (Line 18) Adults age 18 or older, seen after 18th birthday, who had at least one medical visit during the reporting period who, (1) during the current or prior year, were diagnosed with IVD OR (2) were discharged after coronary artery bypass surgery (CABG) or percutaneous transluminal coronary angioplasty (PTCA) or acute myocardial infarction (AMI) between January 1, and November 1, of the year prior to the measurement year are reported on Line 18. For the purposes of this year’s reporting this includes all medical patients meeting the clinical profile who were born on or before December 31, 1997. Section K: Colorectal Cancer Screening (Line 19) Adults age 51 through 74, who had at least one medical visit during the reporting period, are reported on Line 19. For the purposes of this year’s reporting this includes medical patients whose date of birth is between January 1, 1941, and December 31, 1964. Section L: HIV Linkage to Care (Line 20) Patients who were diagnosed for the first time ever with HIV between October 1, 2014, and September 30, 2015 are reported on Line 20. Section M: Patients Screened for Depression and Follow-up (Line 21) Patients age 12 and older, who had at least one medical visit during the reporting period, are reported on Line 21. For the purposes of this year’s reporting this includes medical patients who were born on or before December 31, 2003. Section N: Dental Sealants (Line 22) Patients age 6 through 9, who had an oral assessment or comprehensive or periodic oral evaluation visit during the reporting period who are at moderate to high risk for caries, are reported on Line 22. For the purposes of this year’s reporting this includes all dental patients meeting the assessment profile whose date of birth is between January 1, 2006, and December 31, 2009. Data for Columns B and C of these sections may be obtained from an Electronic Health Record (EHR) that includes at least 80% of the patients who fit the criteria described in this section or 92 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

from an audit of charts selected through a process of scientific random sampling (methods described in Appendix C).

Column Instructions Column A: Number of Patients in the “Universe” Enter the total number of health center patients who fit the detailed criteria described below. Column A will reflect the total number of patients meeting the criteria in the agency’s total patient population including all sites and all programs. Because the initial patient population for each measure is defined in terms of age (or age and gender), comparisons to the numbers on Table 3A and Table 6B will be made when evaluating your submission. The numbers in column A of Table 6B will not be equal to those which might be calculated on Table 3A for the following reasons: 1) All patients seen for all reportable services are counted on Table 3A, but the clinical measures reported on Table 6B relate to medical patients or dental patients (specific to one measure only) or to patients with specific conditions 2) Table 3A measures age as of June 30 of the calendar year but Table 6B defines specific time period (i.e., by December 31) to measure age. 3) Some Table 6B measures require that the patient has had more than one visit, but Table 3A reflects patients with one or more visit. Column B: Number of Charts/Records Sampled or EHR Total Enter the total number of health center patients from the universe (Column A) for whom data have been reviewed. The number will be: •

all patients who fit the criteria (and hence the same number as the universe reported in Column A) or

a scientifically drawn sample of 70 patients selected from all patients who fit the criteria or

a number equal to or greater than 80% of all patients who fit the criteria (and hence a value no less than 80% of the universe reported in Column A).

If a sample is to be used it must be a sample of 70 and must be drawn from the entire patient population identified as the universe. 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 as this will result in over-sampling some group of patients. A review of a sample of charts must be used in lieu of full universe reporting from an EHR if: •

The EHR does not include a minimum of 80% of health center patients who meets the criteria described below for inclusion in the specific measure’s universe.

The EHR does not exclude every single health center patient who meets one or more exclusion criteria described below for exclusion from the universe.

The look-back period data necessary for many of the UDS clinical quality measures (e.g., cervical cancer screening, colorectal cancer screening, childhood immunizations) has not been in place in the EHR long enough to be able to find the data required in prior year’s activities or this documented data was not collected from the patient as part of the visit. It is recommended records for new patients be obtained from their former providers to document their prior treatment including data for look-back periods. Medical records

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obtained from other providers may be recorded in the health center’s EHR consistent with internal medical records policies, at which point they could be used in the calculated performance rate for the applicable measure. If the EHR is used, the number in Column B (records reviewed) must be no less than 80% of the number in Column A when the total universe 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: Number of Charts/Records Meeting the Measurement Standard Enter the total number of records which meet the measurement standard as discussed below. The number in Column C (patients meeting the measurement standard) may never exceed the number in Column B (patient records reviewed).

Defining the Universe: “Criteria” vs. “Exclusions” in EHRs vs. Chart Reviews

Because the UDS follows the structure developed for Meaningful Use and other systems, conditions may sometimes be listed as criteria and sometimes as exclusions. They should be treated as described here to either constrain the universe of an EHR report or identify charts to be replaced in a chart review process. In the discussion which follows the concepts of “conditions” or “criteria” are at times juxtaposed with “exclusions.” This is partly because of the differing language and procedures in an EHR (or PMS) based report versus a Chart Audit report. In an EHR or PMS review, all criteria for a measure must be able to be found in the EHR and must be in the EHR for each and every patient at the health center. To the extent that they cannot be found, they will distort the findings, and means that the EHR must not be used. If, for example, the EHR cannot differentiate between a medical patient and a dental-only patient, then the EHR cannot be used to review the immunization of 3 year olds because you cannot limit the universe to medical patients. In a sample chart review process, items listed as “criteria” below may be used as “exclusions.” Thus, you can ask that all 3 year old patients be listed and, if your sample includes someone who turns out to be a dental (only) patient, you can “exclude” that chart from the sample and replace it with another chart. (In a computer search you would include as a criteria that they must be medical patients for the immunization measure.)

Detailed Instructions for Clinical Measures

What follows is a detailed discussion of each of the clinical measures. BPHC recognizes that some health centers may have different staff people working on each of the measures. Because of this, these pages have been designed so that the instructions for each of the measures are complete in and of themselves. As a result, instructions that apply to more than one measure will be duplicated to permit extraction of that portion of the manual. In this section, when conditions are linked with “and” it means that each of the conditions must be met independently. If some, but not all of the conditions are met, the services for that patient are considered to have failed to meet the measurement standard. Where conditions are linked with “or” it means that if either of the conditions is met the measure is satisfied. Note that some of the newer measures do not correspond directly with traditional ICD-9, ICD10, or CPT codes. As a result, we have also included some CPT Category II codes (shown as CPT-II) which are specific to performance measures. These may be found in an appendix to most CPT manuals titled Category II Codes. 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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Childhood Immunization (Line 10) Performance Measure: The performance measure is “Percentage of children with their 3rd birthday during the measurement year who are fully immunized before their third birthday.” This is calculated as follows: •

Numerator: Number of children among those included in the denominator who were fully immunized before their 3rd birthday; a child is fully immunized if s/he has been vaccinated or there is documented evidence of contraindication for the vaccine or a history of illness for ALL of the following prior to their third birthday: 6 o 4 DTP/DTaP, o 3 IPV, o 1 MMR, o 3 Hib, o 3 HepB, o 1VZV (Varicella), and o 4 Pneumococcal conjugate Denominator: Number of all children with at least one medical visit during the reporting period, who had their 3rd birthday during the reporting period; for measurement year 2015, this includes all children with date of birth between January 1, 2012, and December 31, 2012. Children who were never seen by the clinic prior to their third birthday are to be excluded. There will no doubt be a number of children for whom no vaccination information is available and/or who were first seen at a point when there was simply not enough time to fully immunize them prior to their third birthday. They still must be included in the universe and thus in the denominator. Total Number of Patients with 3rd Birthday during Measurement Year, Column (A) Enter number of children who: •

Were born between January 1, 2012, and December 31, 2012, and

Had at least one medical visit during the reporting year, including children who were seen only for the treatment of an acute or chronic condition and those who were never seen for well child care and

Were seen for the first time ever prior to their third birthday. (This could have been in 2012, 2013, 2014, or 2015.)

Include all children meeting this criterion regardless of whether they came to the health center for well child 7 services or other medical services which include vaccinations or they came for treatment of an injury or illness. Note that children whose only service was receipt of a vaccination, and who never received other services, are not to be counted as patients on any of the demographic tables and are not included in the universe for this table. Children who had a contraindication for a specific vaccine should be included in the universe. In your review, they should be counted as being “compliant” for that specific

6

This measure is aligned with the Healthy People 2020 IID-8 measure. Health centers should add to their universe 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 as well.

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vaccine and then reviewed for the administration of the rest of the vaccines. Contraindications should be looked for as far back as possible in the patient’s history. The following may be used to identify contraindications which permit allowable vaccination-exclusions: •

Any particular vaccine: Allergic reaction to the vaccine or its components: ICD-9: 999.4; ICD-10: T80.51-.

DTaP: Encephalopathy ICD-9: 323.5 (must include E948.4 or E948.5 or E948.6 to identify the vaccine) or 323.6x; ICD-10: G04.01, G04.02, G04.32 (use T50.A-, T50.B-, T50.Z- to identify vaccine) or G04.00, G04.01, G04.30, G04.31, G04.39, G05.4.

VZV, MMR: o

Immunodeficiency, including genetic (congenital) immunodeficiency syndromes ICD-9: 279; ICD-10: D80-, D81- (exclude D81.3, D81.5, D81.81-), D82-, D83-, D84-, D89- (exclude D89.0, D89.1, D89.2)

o

HIV-infected or household contact with HIV infection ICD-9: Infection V08, symptomatic 042; ICD-10: B20, Z21

o

Cancer of lymphoreticular or histiocytic tissue ICD-9: 200-202; ICD-10: C81-, C83-, C82-, C84.0-, C84.1-, C84.4-, C84.6-, C84.7-,C84.9-, C84.A-, C84.Z-, C85-, C86-, C88.4, C91.4-, C96- (exclude C96.5, C96.6)

o

Multiple myeloma ICD-9: 203; ICD-10: C90-, C88- (exclude C88.0). Leukemia ICD-9: 204-208; ICD-10: C91- (exclude C91.4-), C92-, C93.0-, C93.1-, C93.3-, C93.Z-, C93.9-, C94- (exclude C94.4-), C95-, D45

o

Allergic reaction to neomycin

IPV: Allergic reaction to streptomycin, polymyxin B, or neomycin

Hib: None

Hepatitis B: Allergic reaction to common baker’s yeast

Pneumococcal conjugate: None

Number of Charts Sampled or EHR Total, Column (B) Enter the total number of health center patients from the universe (Column A) for whom data have been reviewed. This will be all patients who fit the criteria; or, if an EHR is used to report, a number equal to no less than 80% of Column A; or, a scientifically drawn sample of 70 patients from all patients who fit the criteria. If a sample is to be used it must be a sample of 70 and must be drawn from the entire patient population who fit the criteria (the universe reported in Column A). 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 that result in oversampling some group of patients. If a health center’s EHR is only able to provide data for a subset of column A, it must be greater than or equal to 80% of column A and must not be restricted by any variable related to the test measure. For example, if the health center only has immunization data for those patients in their immunization registry, this would be unacceptable even if it were greater than 80% of the patients in Column A.

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In the event that fewer than 70 patients meet the criteria and are reported in Column A, the number in Column B must be the same as in Column A. Number of Patients Immunized, Column (C) Enter in Column C the number of children from Column B who have received all of the following: 4 DTP/DTaP, 3 IPV, 1 MMR, 3 Hib, 3 HepB, 1VZV (Varicella), and 4 Pneumococcal conjugate prior to their 3rd birthday. In addition to those who have documentation of receiving the vaccine, count any of the following as documenting meeting the measurement standard for a given vaccine: evidence of the antigen, contraindication for the vaccine, documented history of the illnesses, or a seropositive test result. For combination vaccinations that require more than one antigen (i.e., DTaP and MMR), find evidence of all the antigens. •

DTaP/DT: At least four DTaP before the child’s third birthday; any vaccination administered prior to 42 days after birth cannot be counted. DT vaccine does not contain pertussis and can be used as a substitute for children who cannot tolerate pertussis vaccine.

IPV: At least three polio vaccinations (IPV) with different dates of service before the child’s third birthday; IPV administered prior to 42 days after birth cannot be counted.

MMR: At least one measles, mumps, and rubella (MMR) vaccination, with a date of service falling before the child’s third birthday

HIB: Three H influenza type B (HiB) vaccinations, with different dates of service before the child’s third birthday; HiB administered prior to 42 days after birth cannot be counted.

Hepatitis B: Three hepatitis B vaccinations, with different dates of service before the child’s third birthday

VZV (Varicella): At least one chicken pox vaccination (VZV), with a date of service falling on or after the child’s first birthday and before the child’s third birthday

Pneumococcal conjugate: At least four pneumococcal conjugate vaccinations before the child’s third birthday

The following ICD-9, ICD-10, and/or CPT codes are evidence of meeting the measurement standard either by providing the vaccine or by having an exempting condition. NOTE: Additional vaccines for these diseases—especially combination vaccines—may have been approved and their CPT codes may be added by health centers to demonstrate meeting the measurement standard. Others listed here, especially those for single diseases covered by the MMR or MMRV vaccines may no longer be manufactured. NOTE ALSO: Many State and county entities participating in the Vaccines for Children (VFC) program assign their own unique codes to some or all of these vaccines. It is the intent of this report to include all such codes as well. • • • • •

DTaP: CPT (90698, 90700, 90701, 90720, 90721, 90723; ICD-9 (99.39) Diphtheria and tetanus: CPT (90702) Diphtheria: CPT (90719); ICD-9(VO2.4*, 032*, 99.36); ICD-10 (Z22.2, A36-) Tetanus: CPT (90703); ICD-9 (037*, 99.38); ICD-10 (A35) Pertussis: ICD-9 (033*, 99.37); ICD-10 (A37-)

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• • • • • • • • • •

IPV: CPT (90698, 90713, 90723); ICD-9 (V12.02*, 045*, 99.41); ICD-10 (Z86.12, A80-) MMR: CPT (90707, 90710) Measles and Rubella: CPT (90708) Measles: CPT (90705); ICD-9 (055*, 99.45); ICD-10 (B05-) Mumps: CPT (90704); ICD-9 (072*, 99.46); ICD-10 (B26-) Rubella: CPT (90706); ICD-9 (056*, 99.47); ICD-10 (B06-) Hib: CPT (90645, 90646, 90647, 90648, 90698, 90720, 90721, 90737, 90748); ICD-9 (041.5*, 038.41*, 320.0*, 482.2*); ICD-10: B96.3, A41.3, G00.0, J14) Hepatitis B: CPT (90723, 90731, 90740, 90744, 90745, 90747, 90748); ICD-9 (VO2.61*, 070.2*, 070.3*); ICD-10 (B16.0, B16.1, B16.2, B16.9, B17.0, B18.0, B18.1, B19.10, B19.11, Z22.51) VZV: CPT (90396, 90710, 90716); ICD-9 (052*, 053*); ICD-10 (B01-, B02-) Pneumococcal conjugate: CPT (90669, 90670)

*Indicates evidence of disease. A patient who has evidence of the disease prior to age 3 is compliant for the antigen.

For immunization information obtained from the medical record, count patients as meeting the measurement standard for a given vaccine where there is evidence that the vaccine was given from (1) a chart note indicating the name of the specific antigen and the date of the immunization, or (2) a certificate of immunization prepared by an authorized health care provider or agency including the specific dates and types of immunizations administered. Immunization information may also be obtained from an immunization registry maintained by the State or other public body as long as it shows comparable information, but immunization registries generally do not update the EHR data set automatically and may require several queries to use. Registries can be used to fill in any voids in the immunization record at the health center, especially when a sample is used. For documented history of illness or a seropositive test result, find a note indicating the date of the event. The event must have occurred prior to the patient’s third birthday and been confirmed by a clinical provider. Notes in the newborn discharge record indicating that the patient received the immunization "at delivery" or "in the hospital" may be counted toward meeting the measurement standard for some immunizations. This applies only to those vaccines that do not have minimum age restrictions (e.g., prior to 42 days after birth). A note that the "patient is up-to-date" with all immunizations that does not list the dates of all immunizations and the names of immunization agents does not constitute sufficient evidence of immunization for this measure, nor does verbal assurance from a parent or other person that a vaccine has been given. Also, good faith efforts to get a child immunized which fail do not meet the measurement standard, including: •

Parental failure to bring in the patient

Parents who refuse for personal or religious reasons

Parents who refuse because of beliefs about vaccines

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Cervical Cancer Screening (Line 11) Performance Measure: The performance measure is “Percentage of women 21–64 years of age who received one or more Pap tests to screen for cervical cancer.” (Note—this is the same measure that had been previously called “Women 24 through 64” for clarity purposes. No women aged 21, 22, or 23 should be included in the calculation of this measure.) This is calculated as follows: •

Numerator: Number of female patients 24–64 years of age receiving one or more documented Pap tests during the measurement year or during the 2 calendar years prior to the measurement year among those women included in the denominator; or, for women who were 30 years of age or older at the time of the test who choose to also have an HPV test performed simultaneously, if the test was done during the measurement year or during the 4 calendar years prior to the measurement year

Denominator: Number of all female patients age 24–64 years of age during the measurement year who had at least one medical visit during the reporting year; for measurement year 2015, this includes women with a date of birth between January 1, 1951, and December 31, 1991. Total Number of Female Patients 24-64 Years of Age, Column (A) Criteria: Enter the number of all female patients who: •

Were born between January 1, 1951, and December 31, 1991, and

Were first seen by health center prior to their 65th birthday, and

Had at least one medical visit in a clinical setting 8 during 2015.

Exclusions: Women who have had a hysterectomy and who have no residual cervix and for whom the administrative data does not indicate a Pap test was performed. Look for evidence of a hysterectomy as far back as possible in the patient’s history, through either administrative data or medical record review. Surgical codes for hysterectomy are: CPT (51925, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290-58294, 58548, 58550, 58552-58554, 58570-58573, 58951, 58953, 58954, 58956, 59135); ICD-9-CM (68.4-68.8, 618.5); and ICD-10-CM (N99.3). NOTE, however: Because very few health centers perform hysterectomies, the chance of finding these CPT codes is small. The record may, however, contain textual reference to the procedure, and should be searched for this in the event no current Pap test is identified. If a system cannot determine exclusions from the universe, “excludable” women may be included in the universe and only later excluded from the sample, if identified. In these cases, a replacement record will be used. Number of Charts Sampled or EHR Total, Column (B) Enter the total number of health center patients from the universe (Column A) for whom data have been reviewed. This will either be all patients who fit the criteria or (if an EHR

8

The requirement of “in a medical setting” is explicitly designed to exclude from the universe women encountered by homeless or agricultural worker programs in a field setting such as a park or encampment, or in an outreach setting such as a shelter which cannot be configured to permit Pap tests to be conducted. Mobile clinics that are designated by the health center as approved “sites” are considered to be clinical settings and women seen in these clinics are included in the universe. This should not be construed to imply that these women do not need the test.

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is used to report, a number equal to no less than 80% of Column A), or a scientifically drawn sample of 70 patients selected from all patients who fit the criteria. If a sample is to be used it must be a sample of 70 and must be drawn from the entire patient population who fit the criteria (the universe reported in Column A). 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 that result in oversampling some group of patients or exclude one or more of their sites which may not yet be included in their EHR. If a woman in the random selection is found to meet the exclusion criteria, the record is removed from the sample and another woman should be randomly selected to replace her. This can best be accomplished by selecting replacement cases at the same time that the random sample is identified. If a health center’s EHR is only able to provide data for a subset of Column A, it must be greater than or equal to 80% of column A and must not be restricted by any variable related to the test measure. For example, the health center may not use a separate “Women’s Health” database that is restricted to women who are specifically receiving health care focused on the reproductive system. In the event that fewer than 70 patients meet the criteria and are reported in Column A, the number in Column B must be the same as in Column A. Number of Patients Tested, Column (C) Criteria: Enter the total number of female patients included in the sample, who either: •

Received one or more Pap tests in a 3-year period from 2013 through 2015 or

Received one or more Pap tests in a 5-year period from 2011 through 2015 and was 30 years of age or older at the time of her last Pap test and chose to have a Pap test and an HPV test done simultaneously.

Documentation in the medical record of a test performed outside of the health center must include the date the test was performed, who performed it, and the result of the finding. A patient is counted as having had a Pap test if a visit contains any one of the following codes or if a copy of a lab test performed by another provider is in the chart. A chart note which documents the name, date, and results from a test performed by another provider which is based on communications between the clinic and the provider is also acceptable. The following ICD-9, ICD-10, and/or CPT codes are evidence of meeting the measurement standard: •

CPT: PAP = 88141-88155, 88164-88167, 88174-88175; HPV = 87620-87622

ICD-9-CM: 91.46, V72.32; ICD-10-CM: Z01.42

CPT-II: 3015F = Pap test

Do not count as meeting the measurement standard, charts which note a referral to a third party but which do not include a copy of the lab report or a report of some form from the clinician/clinic that provided the test. Do not count as meeting the measurement standard unsubstantiated statements from patients which cannot be backed up with third party documentation. Do not count as compliant charts which note the refusal of the patient to have the test.

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Weight Assessment and Counseling for Children and Adolescents (Line 12) Performance Measure: The performance measure is “Percentage of patients aged 3 -17 years of age who had evidence of BMI percentile documentation and who had documentation of counseling for nutrition and who had documentation of counseling for physical activity during the measurement year.” This is calculated as follows: •

Numerator: Number of patients in the denominator who had their BMI percentile (not just BMI or height and weight) documented during the measurement year and who had documentation of counseling for nutrition and who had documentation of counseling for physical activity during the measurement year

Denominator: Number of patients who were 3 years of age through adolescents who were aged 17 at some point during the measurement year, who had at least one medical visit during the reporting year, and were seen by the health center for the first time prior to their 18th birthday; for measurement year 2015, this includes patients with a date of birth between January 1, 1998, and December 31, 2012. Total Number of Patients 3 through 17 Years of Age, Column (A) Criteria: Enter the number of all patients who: •

Were born between January 1, 1998, and December 31, 2012, and

Were first seen ever by the health center prior to their 18th birthday, and

Had at least one medical visit 9 in a clinical setting 10 during 2015.

Exclusions: Pregnant patients Number of Charts Sampled or EHR Total, Column (B) Enter the total number of health center patients included in the universe (Column A) for whom data have been reviewed. This will be either all patients who fit the criteria or if an EHR is used to report, a number no less than 80% of Column A) or a scientifically drawn sample of 70 patients drawn from all patients who fit the criteria. If a sample is to be used it must be a sample of 70 and must be drawn from the entire patient population. 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 that result in oversampling some group of patients. If a health center’s EHR is only able to provide data for a subset of Column A, it must be greater than or equal to 80% of column A and must not be restricted by any variable related to the test measure. For example, the health center may not use a separate “well child” database that is restricted to children who are specifically receiving well child care.

9

Health centers should add to their universe those patients whose only visits were well child visits (99382-99384, 99392-99394), if their automated system does not include them. In addition, if your State uses different codes for EPSDT visits, those codes should be added as well. 10 The requirement of “in a medical setting” is explicitly designed to exclude from the universe children and adolescents whose only visits have been in homeless or agricultural worker programs in a field setting such as a park or encampment, or in an outreach setting such as a shelter which cannot be configured to permit weight and height measurements. Mobile clinics that are designated by the health center as approved “sites” are considered to be clinical settings and children and adolescents seen in these clinics are included in the universe.

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In the event that fewer than 70 patients meet the criteria and are reported in Column A, the number in Column B must be the same as in Column A. Number of Patients with Documented Counseling and BMI Percentile, Column (C) Enter the total number of patients identified in Column B whose 2015 record demonstrates that their BMI percentile (not just height and weight or numeric BMI score from which the BMI percentile can be calculated) was documented during the measurement year and that they received counseling on nutrition during the measurement year and counseling on physical activity during the measurement year. The following ICD-9, ICD-10, and/or CPT codes are evidence of meeting the measurement standard: •

ICD-9 code V85.5x and ICD-10 code Z68.5- are for recording BMI percentile. Presence is sufficient, but not necessary.

Codes 97802-97804 are for 15 minutes or more of nutritional counseling. Their presence is sufficient but not necessary.

ICD-9 code V65.41 and ICD-10 code Z71.89 is sufficient, but not necessary for physical activity counseling.

Do not count as meeting the performance measure, charts which show only that a wellchild visit was scheduled, provided or billed. The electronic or paper well-child visit template/form must document each of the elements noted above. Adult Weight Screening and Follow-Up (Line 13) Performance Measure: The performance measure is “Percentage of patients aged 18 and older with a documented BMI during the most recent visit or within the 6 months prior to that visit and when the BMI is outside of normal parameters a follow-up plan is documented.” This is calculated as follows: •

Numerator: Number of patients in the denominator who had their BMI (not just height and weight) documented during their most recent visit or within 6 months of the most recent visit and if the most recent BMI is outside of normal parameters, a follow-up plan is documented

Denominator: Number of patients who were 18 years of age or older during the measurement year, who had at least one medical visit during the reporting year; for measurement year 2015, this includes patients with a date of birth on or before December 31, 1997. Total Number of Patients Age 18 and Over, Column (A) Criteria: Enter the number of all patients who: •

Were born on or before December 31, 1997 and

Were last seen by the health center after their 18th birthday, and

Had at least one medical visit in a clinical setting 11 during 2015.

11

The requirement of “in a medical/clinical setting” is explicitly designed to exclude from the universe patients whose only visits have been in homeless or agricultural worker programs in a field setting such as a park or encampment, or in an outreach setting

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Exclusions: •

Pregnant women

Terminally ill patients (no definition is provided)

Number of Charts Sampled or EHR Total, Column (B) Enter the total number of health center patients included in the universe (Column A) for whom data have been reviewed. This will be either all patients who fit the criteria or if an EHR is used to report, a number no less than 80% of Column A) or a scientifically drawn sample of 70 patients selected from all patients who fit the criteria. If a sample is to be used it must be a sample of 70 and must be drawn from the entire patient population who fit the criteria (the universe reported in Column A). 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 that result in oversampling some group of patients. If a health center’s EHR is only able to provide data for a subset of Column A, it must be greater than or equal to 80% of column A and must not be restricted by any variable related to the test measure. For example, the health center may not use a separate database that is restricted to enrollees in a managed care plan who must be provided with weight tracking services. This would be unacceptable even if it were greater than 80% of the patients in Column A. In the event that fewer than 70 patients meet the criteria and are reported in Column A, the number in Column B must be the same as in Column A. Number of Patients with Documented BMI and Follow-Up Plan if Weight is Outside Parameters, Column (C) Enter the total number of patients identified in Column B whose 2015 record demonstrates that their BMI (not just height and weight) was documented during their last visit or within 6 months prior to that visit, and which demonstrates that they received a follow-up plan to address their weight if they: •

Were under age 65 and their BMI was greater than or equal to 25, or

Were age 65 or older and their BMI was greater than or equal to 30, or

Were under age 65 and their BMI was under 18.5, or

Were age 65 or older and their BMI was under 23.

The following codes are evidence of meeting the measurement standard: •

CPT-II: 3008F = BMI documented sufficient, but not necessary

ICD-9: V65.3 and ICD-10: Z71.3 = dietary surveillance and counseling sufficient, but not necessary for follow-up plan

Documentation in the medical record must show the actual BMI or the template normally viewed by a clinician must normally display BMI. Do not count as meeting the measurement standard, charts or templates which display only height and weight. The

such as a shelter which cannot be configured to permit weight and height measurements. Mobile clinics that are designated by the health center as approved “sites” are considered to be clinical settings and patients seen in these clinics are included in the universe.

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fact that an EHR is capable of calculating BMI does not replace the presence of the BMI itself. Tobacco Use Screening and Cessation Intervention (Line 14a) Performance Measure: The performance measure is “Percentage of patients aged 18 and older who were screened for tobacco use at least once during the measurement year or prior year AND who received cessation counseling intervention and/or pharmacotherapy if identified as a tobacco user.” This is calculated as follows: •

Numerator: Number of patients in the denominator for whom documentation demonstrates that patients were queried about their tobacco use one or more times during their most recent visit or within 24 months of the most recent visit and received tobacco cessation counseling intervention and/or pharmacotherapy if identified as a tobacco user

Denominator: Number of patients who were 18 years of age or older during the measurement year, seen after 18th birthday, with at least one medical visit during the reporting year, and with at least two 12 medical visits ever; for measurement year 2015, this includes patients with a date of birth on or before December 31, 1997. Total Number of Patients Age 18 and Over, Column (A) Criteria: Enter the number of all patients who: •

Were born on or before December 31, 1997, and

Were last seen by health center after their 18th birthday, and

Had at least one medical visit during 2015, and

Had at least two medical visits ever.

Exclusions: None Number of Charts Sampled or EHR Total, Column (B) Enter the total number of health center patients included in the universe (Column A) for whom data have been reviewed. This will be either all patients who fit the criteria or if an EHR is used to report, this will be a number no less than 80% of Column A or a scientifically drawn sample of 70 patients drawn from all patients who fit the criteria. If a sample is to be used it must be a sample of 70 and must be drawn from the entire patient population who fit the criteria (the universe reported in Column A). 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 that result in oversampling some group of patients. If a health center’s EHR is only able to provide data for a subset of column A, it must be greater than or equal to 80% of column A and must not be restricted by any variable related to the test measure. In the event that fewer than 70 patients meet the criteria and are reported in Column A, the number in Column B must be the same as in Column A.

12

Two visits are specified in order to ensure that the patient has a relationship with the health center. The universe may be enlarged to include other patients whose relationship is demonstrated by having had a behavioral assessment, concomitant occupational therapy, or concomitant mental health visits; however health centers are not expected to search for these patients.

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Number of Patients Queried about Tobacco Use and Received Cessation Counseling Intervention, As Appropriate, Column (C) Enter the total number of patients identified in Column B whose 2015 record demonstrates that 1) they had been asked about their use of any and all forms of tobacco at their most recent visit or at a visit within 24 months of the last visit and 2) if they are found to be a tobacco user: •

Received tobacco use cessation services, or

Received an order for (a prescription or a recommendation to purchase) a smoking cessation medication; this medication may be a prescription or an Over the Counter (OTC) product. or

Were found to be on (using) a smoking cessation agent.

The following codes will be useful in identifying meeting the measurement standard: CPT/CPT-II/ICD-9/ICD-10 codes: •

CPT-II: 1000F = Tobacco use assessed

CPT-II: 1034F = Current tobacco smoker

CPT-II: 1035F = Current smokeless tobacco user (e.g., chew, snuff)

CPT-II: 1036F = Current tobacco non-user

CPT-II: 4000F = Tobacco use treatment, counseling

CPT-II: 4001F = Tobacco use treatment, pharmacologic treatment

CPT: 99406-07 = Smoking and tobacco use cessation counseling—sufficient, but not necessary

ICD-9: 305.1, 649.00-649.04 = Tobacco use disorder—sufficient, but not necessary

ICD-10: F17-, O99.33- = Tobacco use (smoking) during pregnancy, childbirth and the puerperium Asthma Pharmacologic Therapy (Line 16) Performance Measure: The performance measure is “Percentage of patients aged 5 through 40 with a diagnosis of mild, moderate, or severe persistent asthma who received or were prescribed accepted pharmacologic therapy.” This is calculated as follows: •

• •

Numerator: Number of patients in the denominator who received a prescription for or were provided inhaled corticosteroid or an accepted alternative medication Denominator: Number of patients who were 5 through 40 years of age at some point during the measurement year, who have been seen at least twice in the practice and who had at least one medical visit during the reporting year, who had an active diagnosis of persistent asthma; for measurement year 2015, this includes patients with a date of birth between January 1, 1975, and December 31, 2010. Total Number of Patients Age 5 through 40, Column (A) Criteria: Enter the number of all patients who: •

Were born on or after January 1, 1975, and on or before December 31, 2010, and

Were last seen by health center while they were age 5 through 40 years, and

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Have been seen at least twice (not necessarily in the current year), and

Had at least one medical visit during 2015, and

Were diagnosed with persistent 13 asthma or have persistent asthma as a current diagnosis on a chronic illness form or template.

Exclusions: •

Allergic reaction to asthma medications

Individuals with a diagnosis of asthma who are discovered, upon review, to have intermittent mild asthma, not persistent asthma

Number of Charts Sampled or EHR Total, Column (B) Enter the total number of health center patients included in the universe (Column A) for whom data have been reviewed. This will be either all patients who fit the criteria OR, if an EHR is used to report, this will be a number no less than 80% of Column A OR a scientifically drawn sample of 70 patients drawn from all patients who fit the criteria. If a sample is to be used it must be a sample of 70 and must be drawn from the entire patient population who fit the criteria (the universe reported in Column A). 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 that result in oversampling some group of patients. If a health center’s EHR is only able to provide data for a subset of Column A, it must be greater than or equal to 80% of Column A and must not be restricted by any variable related to the test measure. In the event that fewer than 70 patients meet the criteria and are reported in Column A, the number in Column B must be the same as in Column A. Number of Patients with Persistent Asthma with Pharmacologic Treatment Documented, Column (C) Enter the total number of patients identified in Column B whose 2015 record demonstrates that they had: •

Received a prescription for or were using an inhaled corticosteroid, or

Received a prescription for or were using an acceptable pharmacological agent, specifically: inhaled steroid combinations, anti-asthmatic combinations, antibody inhibitor, leukotriene modifiers, mast cell stabilizers, or methylxanthines.

The following CPT-II/ICD-9/ICD-10 codes will be useful in identifying universe and meeting the measurement standard: •

ICD-9 (493.x) and ICD-10 (J45.x, J45.9x) = Asthma (to narrow the population to be sampled if persistent asthma cannot be determined)

13

It is the clear intent that the universe be limited to patients with persistent asthma and, specifically, that patients with mild intermittent asthma, for which no daily medication is needed, be excluded from the universe. But, while there are CPT Category II codes that differentiate between these conditions, there are no traditional ICD-9 codes which do so. However, there are ICD-10 codes which do. Appendix C describes sampling techniques that can be used to find these patients if CPT-II codes are not being used.

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CPT-II (1038F or 4015F) and ICD-10 (J45.3x, J45.4x, J45.5x) = Persistent asthma, including appropriate pharmacologic treatment prescribed (mild, moderate or severe)

The following CPT-II/ICD-9/ICD-10 codes will be useful in identifying patients to be excluded from the universe: •

CPT-II 1039F and ICD-10 (J45.2x) = Intermittent asthma

Patients whose only pharmacologic treatment using a short-acting bronchodilator for symptomatic relief.

Coronary Artery Disease (CAD): Lipid Therapy (Line 17) Performance Measure: The performance measure is “Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed a lipid-lowering therapy.” This is calculated as follows: •

Numerator: Number of patients in the denominator who received a prescription for or were provided or were taking lipid lowering medications

Denominator: Number of patients who were seen during the measurement year after their 18th birthday, who had at least one medical visit during the reporting year, with at least two medical visits ever, and who had an active diagnosis of coronary artery disease (CAD) including any diagnosis for myocardial infarction (MI) or who had had cardiac surgery in the past; for measurement year 2015, this includes patients with a date of birth on or before December 31, 1997. Total Number of Patients Age 18 and Older with CAD Diagnosis, Column (A) Criteria: Enter the number of all patients who: •

Were born on or before December 31, 1997, and

Were last seen by health center after their 18th birthday, and

Had at least one medical visit during 2015, and

Had at least two medical visits ever, and

Have an active diagnosis of coronary artery disease (CAD) or were diagnosed as having had a myocardial infarction (MI) or have had cardiac surgery 14.

Exclusions: •

Individuals whose last LDL lab test during the measurement year was less than 130 mg/dL

Individuals with an allergy to or a history of adverse outcomes from or intolerance to LDL lowering medications

Number of Charts Sampled or EHR Total, Column (B)

14

A large number of surgical CPT codes relating to the performance of a CABG or PTCA are included in the specifications for cardiac surgery, however these may be difficult to find. Health centers should utilize EHR reporting capabilities to identify patients with a history of pertinent cardiac surgeries.

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Enter the total number of health center patients included in the universe (Column A) for whom data have been reviewed. This will be either all patients who fit the criteria or, if an EHR is used to report, this will be a number no less than 80% of Column A or a scientifically drawn sample of 70 patients drawn from all patients who fit the criteria. If a sample is to be used it must be a sample of 70 and must be drawn from the entire patient population who fit the criteria (the universe reported in Column A). 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 that result in oversampling some group of patients. If a health center’s EHR is only able to provide data for a subset of Column A, it must be greater than or equal to 80% of column A and must not be restricted by any variable related to the test measure. For example, the health center may not use a list of those only seen by their cardiologist. In the event that fewer than 70 patients meet the criteria and are reported in Column A, the number in Column B must be the same as in Column A. Number of Patients Prescribed a Lipid Lowering Therapy, Column (C) Enter the total number of patients identified in Column B whose 2015 record demonstrates that they had •

Received a prescription for or were using a lipid lowering therapy.

The following CPT/ICD-9/ICD-10 codes will be useful in identifying the universe: •

CAD and MI = ICD-9 (410.xx, 411.xx, 412, 413.xx, 414.0x, 414.8, 414.9);ICD-10 (I20-, I21- thru I24-, I25- (excludes I20.0, I25.3, I25.4-, I25.82, I25.83, I25.84))

History of surgeries = ICD-9 (V45.81, V45.82); ICD-10 (Z95.1, Z98.61); CPT (33140, 33510-33514, 33516-33519, 33521-33536, 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92980, 92981, 92982, 92984, 92995, 92996)

Do not count as compliant patients who are receiving a form of treatment other than pharmacologic treatment. Persons involved in therapeutic lifestyle changes and/or control of non-lipid risk factors without concomitant pharmaceutical treatment have not met the measurement standard. Ischemic Vascular Disease (IVD): Aspirin or Anti-Thrombotic Therapy (Line 18) Performance Measure: The performance measure is “Percentage of patients aged 18 years and older who were discharged alive for acute myocardial infarction (AMI) or coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) in the prior year or who had a diagnosis of ischemic vascular disease during 2015 who had documentation of use of aspirin or another antithrombotic.” This is calculated as follows: •

Numerator: Number of patients in the denominator who had documentation of aspirin or another anti-thrombotic medication being prescribed, dispensed, or used

Denominator: Number of patients who were aged 18 and older at some point during the measurement year, who had at least one medical visit during the reporting year, who had an active diagnosis of ischemic vascular disease (IVD) during the current or prior year OR had been discharged after AMI or CABG or PTCA in the prior year; for

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measurement year 2015, this includes patients with a date of birth before December 31, 1997. Total Number of Patients Age 18 and Older with IVD Diagnosis, Column (A) Criteria: Enter the number of all patients who: •

Were born on or before December 31, 1997, and

Were last seen by the health center while they were 18 years of age or older, and

Had at least one medical visit during 2015, and

Had an active diagnosis of ischemic vascular disease (IVD) during 2014 or2015 OR had been discharged after AMI or CABG or PTCA during 2014.

Exclusions: None Number of Charts Sampled or EHR Total, Column (B) Enter the total number of health center patients included in the universe (Column A) for whom data have been reviewed. This will be either all patients who fit the criteria OR, if an EHR is used to report, this will be a number no less than 80% of Column A OR a scientifically drawn sample of 70 patients drawn from all patients who fit the criteria. If a sample is to be used it must be a sample of 70 and must be drawn from the entire patient population who fit the criteria (the universe reported in Column A). 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 that result in oversampling some group of patients. If a health center’s EHR is only able to provide data for a subset of Column A, it must be greater than or equal to 80% of column A and must not be restricted by any variable related to the test measure. For example, the health center may not use a list of only those seen by their cardiologist. In the event that fewer than 70 patients meet the criteria and are reported in Column A, the number in Column B must be the same as in Column A. Number of Patients with Aspirin or Other Anti-Thrombotic Use, Column (C) Enter the total number of patients identified in Column B whose 2015 medical record demonstrates that they had •

Received a prescription for, were given, or were using Aspirin or another antithrombotic drug.

The following CPT/ICD-9/ICD-10 codes will be useful in identifying the universe: •

IVD, AMI = ICD-9 (411.xx, 413.xx, 414.0x, 414.8, 414.9, 429.2, 433.0, 433.01, 433.10, 433.11, 433.20, 433.21, 433.30, 433.31, 433.80, 433.81, 433.90, 433.91, 434, 434.01, 434.10, 434.11, 434.90, 434.91, 440.1, 440.20, 440.21, 440.22, 440.23, 440.24, 440.29, 440.4, 444.0, 444.1, 444.21, 444.22, 444.81, 444.89, 444.9, 445.01, 445.02, 445.8, 445.81, V45.81, V45.82); ICD-10: I20-, I21-, I24-, I25-, I63- thru I63.2-, I63-, I65-, I66-, I70.1, I70.20-, I70.21-, I70.22-, I70.23-, I70.24-, I70.25, I70.26-, I70.29-, I70.92, I74-, I75-, Z95.1, Z98.61 (exclude I25.4-, I25.82, I25.83, I25.84)

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History of surgeries = CPT (33510-33514, 33516-33519, 33521-33523, 33533-33536, 92920, 92924, 92928, 92933, 92937, 92941, 92943)

Colorectal Cancer Screening (Line 19) Performance Measure: The performance measure is “Percentage of patients aged 50 to 75 who had appropriate screening for colorectal cancer.” This is calculated as follows: •

Numerator: Number of patients aged 51 through 74 with appropriate screening for colorectal cancer

Denominator: Number of patients who were aged 51 through 74 at some point during the measurement year, who had at least one medical visit during the reporting year. 15

NOTE: Though age 50 to 75 is in the title of this measure, the detail calls for persons to be screened within a year of turning 50 and prior to reaching age 75. For measurement year 2015, this includes patients whose date of birth is between January 1, 1941, and December 31, 1964. Documented colonoscopy conducted during the measurement year or the previous 9 years or flexible sigmoidoscopy conducted during the measurement year or the previous 4 years meet the measurement standard criteria. Though codes are shown for colonoscopy and flexible sigmoidoscopy, it is possible that these CPT codes may not be found in the health center’s EHR or other computerized system. It is possible that the procedures were performed elsewhere, but confirmation of this is required by having in the chart either a copy of the test results or correspondence between the clinic staff and the performing lab/clinician showing the results of the test. Fecal occult blood test (FOBT), including the fecal immunochemical test (FIT), can also be used to document meeting the measurement standard. Since the FOBT is to be conducted annually, evidence of a test is required during the measurement year. Thus, a patient who had an FOBT in November 2014, (for example) would still need one in 2015 even if the patient did not present in the clinic after June of 2015. Stool specimens for FOBT, including FIT, should be collected by patients at home, as recommended by the manufacturer. An in-office obtained stool specimen (including a sample obtained through a digital rectal examination) does not meet the measurement standard, nor does it comply with manufacturers’ recommendations or national screening guidelines. Test kits can be mailed to patients during the year, but receipt and processing of the test sample is required. Evidence of mailing is not, in and of itself, sufficient. Total Number of Patients Age 51 through 74, Column (A) Criteria: Enter the number of all patients who: •

Were born between January 1, 1941, and December 31, 1964, and

Had at least one medical visit during 2015.

Exclusions: Patients who have or who have had colorectal cancer or colectomy Number of Charts Sampled or EHR Total, Column (B) Enter the total number of health center patients included in the universe (Column A) for whom data have been reviewed. This will be either all patients who fit the criteria OR, if an EHR is used to report, this will be a number no less than 80% of Column A OR a scientifically drawn sample of 70 patients drawn from all patients who fit the criteria.

15

The CMS Meaningful Use criteria for this measure includes persons seen at any point within the last two years, however, for the purposes of reporting in UDS Table 6B, medical patients must have had one medical visit during the current measurement year.

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If a sample is to be used it must be a sample of 70 and must be drawn from the entire patient population who fit the criteria (the universe reported in Column A). 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 that result in oversampling some group of patients. If a health center’s EHR is only able to provide data for a subset of Column A, it must be greater than or equal to 80% of Column A and must not be restricted by any variable related to the test measure. In the event that fewer than 70 patients meet the criteria and are reported in Column A, the number in Column B must be the same as in Column A. Number of Patients with Appropriate Screening for Colorectal Cancer, Column (C) Enter the total number of patients identified in Column B whose 2015 record demonstrates that they had: •

a colonoscopy after January 1, 2006, or

a flexible sigmoidoscopy after January 1, 2011, or

a fecal occult blood test (FOBT), including the fecal immunochemical (FIT) test during the measurement year.

The following CPT/CPT-II/ICD-9/ICD-10 codes will be useful in identifying meeting the measurement standard: •

ICD-9 = 45.22 - 45.25, 45.42 - 45.43, V76.51

ICD-10 = Z12.11

CPT = 44150-44158, 44210-44212, 44388 - 44397, 45330 - 45345, 45355, 45378 - 45392, 82270, 82274,

CPT – II = 3017F

HIV Linkage to Care (Line 20) Performance Measure: The performance measure is “Percentage of newly diagnosed HIV patients who had a medical visit for HIV care within 90 days of first-ever HIV diagnosis. 16 This is calculated as follows: •

Numerator: Number of patients in the denominator who had a medical visit for HIV care within 90 days of first-ever HIV diagnosis

Denominator: Number of patients first diagnosed with HIV between October 1, of the prior year through September 30, of the current measurement year Total Number of Patients with a First Time Ever Diagnosis of HIV, Column (A) Criteria: Enter the number of all patients who: •

16

Were diagnosed with HIV for the first time ever 17 between October 1, 2014, and September 30, 2015 18, and

Note that this measure does not conform to the calendar year reporting requirement.

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Had at least one medical visit during 2015 or 2014.

Note that the identification of patients for this measure crosses years and may include prior year patients. Exclusions: None Number of Charts Sampled or EHR Total, Column (B) Enter the total number of health center patients included in the universe (Column A) for whom data have been reviewed. For this measure, this will almost always be all patients who fit the criteria (i.e., the same number as in Column A) or, if an EHR is used to report, this will be a number no less than 80% of Column A OR a scientifically drawn sample of 70 patients drawn from all patients who fit the criteria.. If a sample is to be used it must be a sample of 70 and must be drawn from the entire patient population who fit the criteria (the universe reported in Column A). 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 that result in oversampling some group of patients. If a health center’s EHR is only able to provide data for a subset of Column A, it must be greater than or equal to 80% of Column A and must not be restricted by any variable related to the test measure. In the event that fewer than 70 patients meet the criteria (which will likely be the case for most health centers for this measure) and are reported in Column A, the number in Column B must be the same as in Column A. Number of Patients with Appropriate Follow-Up, Column (C) Enter the total number of patients identified in Column B whose record demonstrates that, within 90 days of the visit where they were tested positive for HIV they had •

A medical visit with a health center provider who initiates treatment for HIV, or

A visit with a referral resource who initiates treatment for HIV.

Note: The numerator criteria are only fulfilled when the patient attended the medical visit for HIV care within 90 days of HIV 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 closed during the 90 day period. That is, the referring provider receives confirmation from the provider to whom the patient was referred that the visit was completed. Also note: Within 90 days of HIV diagnosis actual treatment must be initiated, not just a referral made or education provided or retesting at the referral site. The following codes will be useful in identifying meeting the measurement standard: CPT/ICD-9 (CPT-II codes): •

ICD-9 = 042, 079.53, V08; ICD-10 = B20, B97.35, Z21

17

“Patients first diagnosed with HIV” is defined as patients who received a reactive initial HIV test confirmed by a positive supplemental HIV test. 18 Because the measure gives up to 90 days to complete the follow-up, you look back 90 days to find the entire universe of patients who should have had a follow-up during the measurement year.

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NOTE however, that these codes will identify ALL patients with HIV. There is no code for newly diagnosed HIV patients. Health centers who expect to see a very small number of such patients should develop alternative methods for tracking within the EHR or medical record. Patients Screened for Depression and Follow-Up (Line 21) Performance Measure: The performance measure is “Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND follow-up plan documented.” This is calculated as follows: •

Numerator: Number of patients aged 12 and older who were 1) screened for depression with a standardized tool and, if screened positive for depression, 2) had a follow-up plan documented.

Denominator: Number of patients who were aged 12 or older at some point during the measurement year and who had at least one medical visit during the reporting year; for measurement year 2015, this includes patients whose date of birth is on or before December 31, 2003. Total Number of Patients Aged 12 or Older, Column (A) Criteria: Enter the number of patients who: •

Were born on or before December 31, 2003, and

Had at least one medical visit during 2015.

Exclusions: •

Patients with an active diagnosis for depression or bipolar disorder

Patients who are already participating in on-going treatment for depression

Number of Charts Sampled or EHR Total, Column (B) Enter the total number of health center patients included in the universe (Column A) for whom data have been reviewed. This will be either all patients who fit the criteria OR, if an EHR is used to report, this will be a number no less than 80% of Column A OR a scientifically drawn sample of 70 patients drawn from all patients who fit the criteria. If a sample is to be used it must be a sample of 70 and must be drawn from the entire patient population who fit the criteria (the universe reported in Column A). 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 that result in oversampling some group of patients. If a health center’s EHR is only able to provide data for a subset of Column A, it must be greater than or equal to 80% of column A and must not be restricted by any variable related to the test measure. For example, the health center may not use a separate “behavioral health” database that is restricted to patients who are in their integrated care program. In the event that fewer than 70 patients meet the criteria and are reported in Column A, the number in Column B must be the same as in Column A. Number of Patients with Appropriate Screening for Depression and Follow-Up, If Appropriate, Column (C)

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Enter the total number of patients identified in Column B whose 2015 record demonstrates that they had a standardized depression screening test during the measurement year: •

Which was negative, or

Which was positive and had a follow-up plan documented.

The following CPT-II codes will be useful in identifying meeting the measurement standard: •

CPT–II = 3725F

Dental Sealants (Line 22) Performance Measure: The performance measure is “Percentage of children, aged 6 through 9, at moderate to high risk for caries who received a sealant on a first permanent molar during the reporting period.” This is calculated as follows: •

Numerator: Number of dental patients aged 6 through 9 who were at moderate to high risk for caries who received a sealant on a permanent first molar tooth in the measurement year.

Denominator: Number of dental patients aged 6 through 9 who had an oral assessment or comprehensive or periodic oral evaluation visit during the reporting year and documented as having moderate to high risk for caries; for measurement year 2015, this includes patients whose date of birth is between January 1, 2006 and December 31, 2009. Total Number of Patients Aged 6 through 9, Column (A) Criteria: Enter the number of dental patients who: •

Were born between January 1, 2006 and December 31, 2009, and

Had at least one oral assessment or comprehensive or periodic oral evaluation visit 19 during 2015, and

Were at moderate to high risk for caries.

Exclusions: •

Children for whom all first permanent molars are non-sealable (i.e., molars are either decayed, filled, currently sealed, or un-erupted/missing)

Number of Charts Sampled or EHR Total, Column (B) Enter the total number of health center dental patients included in the universe (Column A) for whom data have been reviewed. This will be either all patients who fit the criteria OR if an EHR is used to report, this will be a number no less than 80% of Column A OR a scientifically drawn sample of 70 patients drawn from all patients who fit the criteria. If a sample is to be used it must be a sample of 70 and must be drawn from the entire patient population who fit the criteria (the universe reported in Column A). Larger samples will not be accepted. Health centers may not choose to select the same number

19

As defined on the UDS. See visit criteria described on Table 5, page 59

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of charts from each site or the same number for each provider or use other stratification mechanisms that result in oversampling some group of patients. If a health center’s EHR is only able to provide data for a subset of Column A, it must be greater than or equal to 80% of Column A and must not be restricted by any variable related to the test measure. In the event that fewer than 70 patients meet the criteria and are reported in Column A, the number in Column B must be the same as in Column A. Number of Patients with Sealants to First Molars, Column (C) Enter the total number of patients identified in Column B whose 2015 record demonstrates that they had a sealant on a permanent first molar during the measurement year. The following CDT codes will be useful in identifying the universe: •

CDT = D0602 and D0603 for caries risk assessment of moderate or high risk

CDT = D0191 for oral assessment performed

CDT = D0120, D0145, D0150, D0180 for comprehensive or periodic oral evaluation

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Questions and Answers for Table 6B 1. Are there any changes to the table this year? Yes, a new dental sealant measure has been added. In addition, as with Tables 6A and 7, use of both ICD-9 and ICD-10 codes will apply to identify patients with specific diagnosis. Careful attention is required to ensure that patients are only counted once with the condition although both ICD-9 and ICD-10 codes may both be used to help identify a patient with specific diagnosis. Also, if a health center’s EHR is only able to provide data for a subset of Column A, it must be greater than or equal to 80% of Column A and must not be restricted by any variable related to the test measure. In the event that fewer than 70 patients meet the criteria and are reported in Column A, the number in Column B must be the same as in Column A. 2. A child came in only once during the year for an injury and never returned for well child care. If her record is selected for the immunization measure sample do we have to consider her chart to not have met the measurement standard? Yes. Once a patient enters a health center’s system of medical care, the center is expected to be responsible for providing all needed preventive health care and/or document that s/he has received it. 3. What if a woman we treat for hypertension and diabetes goes to an ObGyn in the community for her women’s health care? Do we still have to consider her in our universe for the Pap test measure? What if we do not do Pap tests? Once the patient has been seen in your clinic, you are responsible for 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 of Pap tests directly in order to obtain appropriate documentation. The woman would be considered to be a part of your universe if she received any medical visit(s) in 2015. If there is no copy of the results of her Pap test included in her chart, she would be considered having not met the measurement standard. 4. If we pull a record during our sampling process for a woman who we sent to the health department for her Pap test, but the results are not posted, can we call the health department, get the results, post them, and then count the record as having met the measurement standard? The health center should obtain a copy of her test result to include in the patient’s record for future care. However, the record still has not met the measurement standard for the reporting year (although the record may now be valid for successive years depending on when the test was performed). 5. If we inform parents of the importance of immunizations but they refuse to have their child immunized, may we count the record as having met the measurement standard if the refusal is documented? No. A child is fully immunized if and only if there is documentation the child received the vaccine or there is contraindication for the vaccine, evidence of the antigen, and history of illness for all required vaccines. 6. Are parents required to bring to the health center documentation of childhood immunizations received from outside the health center? 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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Parents are encouraged to provide documentation of immunizations that their children receive elsewhere, but other mechanisms of obtaining this information are also acceptable. Health centers are encouraged to document childhood immunizations by contacting providers of immunizations directly in order to obtain documentation by fax, or by requesting health center patients to mail a copy of their immunization history, or by finding the child in a State or county immunization registry or through other appropriate means. 7. Some of the immunization details are different than those used by CDC in the CASA or CO-CASA reviews of our clinic. May we use these CDC standards to report on the UDS? No. HRSA is now using one of the Healthy People 2020 standards to evaluate provision of vaccines to children. Using a different set of standards will distort the data. Because data are being compared to Table 3A data, such misalignment may be detected in which case health centers will be asked to resample their data. A center may use a different set of standards for its own internal quality improvement/quality assurance program, or to meet the CMS Meaningful Use criteria, but these may not be substituted for the BPHC measure definitions for the UDS reporting on Table 6B. 8. We want to use these reviews to compare our sites and our providers to one another. As a result, we would like to use a larger universe. Is there any problem with this? Yes. First, all health centers using a sample must use 70 charts. This facilitates the development of state, national, and other roll-up reports. Second, and perhaps more important, any change in the sample size as described would bias the sample and provide distortions in the data set. A health center may draw a larger random sample and use only the first 70 for the UDS, but the larger sample must be a random sample of the entire organization—it may not oversample specific sites or providers to facilitate internal QI activities. 9. What happens if the CPT or ICD codes change again? The codes are reviewed annually by the UDS Support Center staff. If you think that there is a CPT or ICD code for a measure which is not being reflected in the list, contact the UDS Support Center. It will review the code with BPHC and incorporate approved changes to codes into the manual for future reporting. 10. Is the Pap test review for women starting at age 21 or at age 24? For this measure you will look only at women who were 24 years or older (up to age 65) at some point in 2015. You will not look at any women who were 21, 22, or 23 years old at the end of 2015. Because the measure asks about Pap tests administered in 2015 or in 2014 or in 2013, it is possible that a 24 year old woman would have been 21 in 2013. If she received a Pap test in that year she would be considered to have met the measurement standard. You are looking only at women who are 24 through 64, but their qualifying test may have been received when they were 21 through 64. Health centers should take care to review charts only for women who were 24 through 64 in 2015, and should not select any charts for women who were younger. 11. When the listing of CPT codes says “sufficient, but not necessary” what does this mean? The codes are generally for activities which, if undertaken, make it obvious that the criteria were met. But there are other ways to meet the criteria as well. For example, the code may be for “tobacco use disorder.” If a provider codes this, it is clear that they have evaluated the patient for tobacco use and its presence in the chart is sufficient to document the evaluation. 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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But this code is not necessary. The patient could have been evaluated for tobacco use without this diagnosis ever being made. 12. Does “counseling for nutrition and ... physical activity” have specific content that must be provided? Does it need to be provided if the child is well within the “normal” range? No, the counseling has no specific required content. It is tailored by the clinician given the patient’s BMI percentile. But, 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. Starting children and adolescents off right is important in efforts to improve long term health outcomes and quality of life. 13. I have a patient who turned 2 in November 2015. Should she be included in the Child and Adolescent weight measure? Does this measure start at age 2 or age 3? No—do not include the child. The measure looks at children who were two, but allows the measurement to be recorded up to one year after her second birthday. Since she still has ten months for her BMI percentile to be charted and for her parents to receive counseling, she would not be included in the universe. For this measure you will look only at children and adolescents who were 3 years or older (through age 17) at some point in 2015. You will not look at any child or adolescent who had not yet turned 3 or who was over 17 years old at the end of 2015. For children who are 3, the documentation for weight assessment and counseling may have been when they were 2. 14. For adult patients, our protocol calls for a weight to be measured at every visit, but for height to be measured “at least once every two years.” Is this acceptable? BMI is calculated from current height and weight. Inasmuch as height in adults does not normally change more than a quarter of an inch in a 2-year period, it is reasonable to follow such a protocol if it has been approved by your clinical staff. 15. The measure says that there must be effective intervention for tobacco users. Are there specific interventions that must be used in order to consider them effective? No. This is at the discretion of the clinicians and should be consistent with their assessment of the patient’s level of tobacco use. As long as the clinicians document that they intervened and this intervention is consistent with the health center’s own protocols, the treatment has met the measurement standard for this measure. 16. If our provider documents that s/he felt maintaining a dust free environment and a diet low in allergens coupled with a “rescue inhaler” is adequate to treat a persistent asthmatic, can we consider this patient’s treatment to have met the measurement standard? No. For persistent asthma one of the listed pharmacologic interventions is required. Rescue inhalers are not contraindicated, but they are not sufficient to meet the requirement of a pharmacologic intervention. 17. Who are we to consider as having been first diagnosed with HIV? Line 20, HIV Linkage to Care asks for a count of the number of health center patients who (any provider in) your practice diagnosed with HIV where this was the first time the patient had ever been told they had HIV. The following might clear some of the ambiguity.

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Do not include patients who: •

Were diagnosed elsewhere and can provide documentation of the positive test result

Were diagnosed elsewhere, referred to you for treatment, and 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 then sent to another provider for definitive testing and treatment.

Do include patients who: •

Were referred to you after a (positive) reactive initial HIV test, but did not have a supplemental test

Self-identify as being HIV positive, but cannot provide documentation of an HIV positive test result

Note that there are no ICD-9 or ICD-10 or CPT codes to identify this condition. Health centers should either modify their EHR to record this information or keep track of the patients who are identified in a separate system. 18. How should we collect data for measures that require a look-back period? Many of the UDS clinical quality measures require a look-back period (e.g., cervical cancer screening, colorectal cancer screening, childhood immunizations, and others). It is important that this information is noted in patient records. It is recommended records for new patients be obtained from their former providers to document their prior treatment including data for look-back periods. Medical records obtained from other providers may be recorded in the health center’s EHR consistent with internal medical records policies, at which point they could be used in the calculated performance rate. 19. Can we use National Quality Forum (NQF) or Clinical Quality Measures (CQMs) directly to report on the clinical measures? Not directly. Health centers must report on the clinical measures outlined according to the UDS definitions outlined in this manual although the use of official versions of vocabulary value sets as contained in the Value Set Authority Center (VSAC) may be used by organizations capable of appropriately using this resource to support the reporting of quality of care measures. 20. Which dental patients are we required to report in the universe for the dental sealants measure? Health centers providing dental services directly on site or through paid referral under contract must report dental patients age 6 through 9 with elevated risk for caries in the universe count.

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Table 6B: Quality of Care Measures Reporting Period: January 1, 2015 through December 31, 2015

Line 1 2 3 4 5 6

Line 7 8 9

Line

10

Line

11

Line

12

Section A - Age Categories for Prenatal Care Patients: Demographic Characteristics of Prenatal Care Patients Age Number of Patients (a) [blank for demonstration] Less than 15 years [blank for demonstration] Ages 15-19 [blank for demonstration] Ages 20-24 [blank for demonstration] Ages 25-44 [blank for demonstration] Ages 45 and over [blank for demonstration] Total Patients (Sum lines 1-5) Section B - Trimester of Entry into Prenatal Care Women Having First Women Having First Trimester of Entry into Prenatal Care Visit with Health Visit with Another Center (a) Provider (b) [blank for demonstration] [blank for demonstration] First Trimester [blank for demonstration] [blank for demonstration] Second Trimester [blank for demonstration] [blank for demonstration] Third Trimester Section C - Childhood Immunization Total Number of patients with 3rd Number Charts Number of Patients birthday during Sampled Childhood Immunization Immunized measurement or EHR total (c) year (b) (a) [blank for demonstration] [blank for [blank for demonstration] MEASURE: Children who have demonstration] received age appropriate rd vaccines prior to their 3 birthday during measurement year (on or prior to December 31) Section D - Cervical Cancer Screening Total number of Number Charts Female Patients Number of Patients Sampled or Cervical Cancer Screening 24-64 years of Tested EHR total Age (c) (b) (a) [blank for [blank for [blank for demonstration] MEASURE: Female patients demonstration] demonstration] aged 24-64 who received one or more Pap tests to screen for cervical cancer Section E - Weight Assessment and Counseling for Children and Adolescents Total patients Number of Patients Weight Assessment and Number Charts aged 3-17 on with Counseling Counseling for Children and Sampled or December 31 and BMI Adolescents EHR Total (b) (a) Documented (c) [blank for [blank for [blank for demonstration] MEASURE: Children and demonstration] demonstration] adolescents aged 3 until17 during measurement year (on or prior to 31 December) with a BMI percentile, and counseling on nutrition and physical activity documented for the current year

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Section F - Adult Weight Screening and Follow-Up

Line

13

Line

14a

Line

16

Line

17

Adult Weight Screening and Follow-Up MEASURE: Patients aged 18 and older with (1) BMI charted and (2) follow-up plan documented if patients are overweight or underweight

Total Patients Aged 18 and Older (a) [blank for demonstration]

Number Charts Sampled or EHR Total [blank for demonstration]

Number of Patients with BMI Charted and Follow-Up Plan Documented as Appropriate (c) [blank for demonstration]

Section G - Tobacco Use Screening and Cessation Intervention Number of patients assessed for Total patients Number Charts tobacco use and Tobacco Use Screening and aged 18 and sampled or provided Cessation Intervention older EHR total Intervention if a (a) (b) Tobacco User (c) [blank for [blank for [blank for demonstration] MEASURE: Patients aged 18 demonstration] and older who (1) were screened demonstration] for tobacco use one or more times in the measurement year or the prior year and (2) for those found to be a tobacco user, received cessation counseling intervention or medication Section H - Asthma Pharmacologic Therapy Total Patients Number Charts aged 5 - 40 with Asthma Pharmacologic Sampled or persistent Therapy EHR Total asthma (b) (a) [blank for [blank for MEASURE: Patients aged 5 demonstration] demonstration] through 40 diagnosed with persistent asthma who have an acceptable pharmacological treatment plan Section I - Coronary Artery Disease (CAD): Lipid Therapy Total Patients Number Charts aged 18 And Coronary Artery Disease Sampled or Older With CAD (CAD): Lipid Therapy EHR Total Diagnosis (b) (a) [blank for [blank for MEASURE: Patients aged 18 demonstration] demonstration] and older with a diagnosis of CAD who were prescribed a lipid lowering therapy

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Number of Patients with Acceptable Plan (c) [blank for demonstration]

Number of Patients Prescribed A Lipid Lowering Therapy (c) [blank for demonstration]

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Line

18

Section J - Ischemic Vascular Disease (IVD): Aspirin or Antithrombotic Therapy Total Patients 18 Number of Patients And Older With With Aspirin or Ischemic Vascular Disease Charts Sampled IVD Diagnosis or Other (IVD): Aspirin or or EHR Total AMI, CABG, or Antithrombotic Antithrombotic Therapy (b) PTCA Procedure Therapy (a) (c) [blank for [blank for [blank for demonstration] MEASURE: Patients aged 18 demonstration] demonstration] and older with a diagnosis of IVD or AMI,CABG, or PTCA procedure with aspirin or another antithrombotic therapy Section K - Colorectal Cancer Screening

Line

Colorectal Cancer Screening

19

MEASURE: Patients age 51 through 74 years of age during measurement year (on or prior to 31 December) with appropriate screening for colorectal cancer

Total Patients 51 through 74 Years of age (a)

Charts Sampled or EHR Total (b)

[blank for demonstration]

[blank for demonstration]

Number of Patients With Appropriate Screening For Colorectal Cancer (c) [blank for demonstration]

Section L - HIV Linkage to Care

Line

HIV Linkage to Care

20

MEASURE: Patients whose first ever HIV diagnosis was made by health center staff between October 1, of the prior year and September 30, of the measurement year and who were seen for follow-up treatment within 90 days of that first ever diagnosis

Line

21

Total Patients First Diagnosed with HIV (a) [blank for demonstration]

Charts Sampled or EHR Total (b) [blank for demonstration]

Number of Patients Seen Within 90 Days of First Diagnosis of HIV (c) [blank for demonstration]

Section M - Patients Screened for Depression and Follow-Up Number of patients Screened for Total Patients Charts Sampled Depression and Patients Screened for Aged 12 and or EHR Total Follow-Up Plan Depression and Follow-Up Older (b) Documented as (a) appropriate (c) [blank for [blank for [blank for demonstration] MEASURE: Patients aged 12 demonstration] and older who were (1) screened demonstration] for depression with a standardized tool and if screening was positive (2) had a follow-up plan documented

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Section N – Dental Sealants Total Patients Aged 6 through 9 Charts Sampled Identified as or EHR Total Moderate to High (b) Risk for Caries (a)

Line

Dental Sealants

22

MEASURE: Children aged 6 through 9 years at moderate to high risk of caries who received a sealant on a permanent first molar tooth

[blank for demonstration]

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[blank for demonstration]

Number of patients with Sealants to First Molars (c) [blank for demonstration]

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Instructions for Table 7: Health Outcomes and Disparities This table reports data on health status measures for birth weight, diabetes, and hypertension by race and Hispanic/Latino ethnicity. All health centers submit Table 7. This table is submitted only in the Universal report. These measures are “process measures” which means that they document measurable outcomes of clinical intervention as a surrogate for good long term health outcomes. Use and analysis of clinical quality measures by health centers in their Plan, Do, Study, Act (PDSA) cycles is one tool that can lead to improved health care for patients. Increasing the proportion of patients who have a good intermediate health outcome generally leads to improved health status of the patient population in the future. Specifically: •

Low Birth Weight: If there are fewer low birth weight children born, then there will be fewer children who suffer the multiple negative sequela of low birth weight, such as delayed or diminished intellectual and/or physical development.

Controlled Hypertension: If there is less uncontrolled hypertension, then there will be less cardiovascular damage, fewer heart attacks, less organ damage later in life.

Poorly Controlled Diabetes: If there is less poorly controlled diabetes, then there will be fewer long-term complications such as amputations, blindness, and end-organ damage.

Table 7 reports health outcome data by race and Hispanic/Latino ethnicity to provide information on health centers’ efforts to help to reduce health disparities. Race and Hispanic/Latino ethnicity is self-reported by patients and should be collected as part of a standard registration process. Care must be taken by health centers which have separate reporting systems for patient registration and clinical data to ensure that race and ethnicity data across the systems are aligned. Health centers who report on a sample of patients – and even those who report on their entire universe 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 impact on disparities for all BPHC-funded programs.

HIV Positive Pregnant Women, Top Line (Line 0)

All health centers are to report the total number of HIV positive pregnant women served by the health center on Line “0” regardless of whether or not they provide prenatal care or HIV treatment for these women.

Deliveries Performed by Health Center Provider (Line 2)

Report the total number of deliveries performed by health center clinicians during the reporting period on Line 2. (This line is not reported by the race or Hispanic/Latino ethnicity of the women delivered.) On this line ONLY, the health center is to include deliveries of women who were not part of the health center’s prenatal care program during the calendar year. This would include such circ*mstances as 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; emergency deliveries when the health center provider is on-call for the emergency room; and deliveries of “undoctored” patients who are assigned to the provider as a requirement for privileging at a hospital. Include as "health center clinicians" any clinician who is paid by the health center while doing the delivery, regardless of the method of compensation. Do not include deliveries where a clinic provider bills separately, receives, and retains payment for the delivery. 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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Deliveries and Birth Weight Measure by Race and Hispanic/Latino Ethnicity, Section A (Columns 1a-1d)

All health centers must report on all prenatal care patients who are either provided direct care or referred for care. No sampling is permitted on this measure. Prior to 2014, only those health centers who directly provided some or all of a patient’s prenatal care reported. Now, all health centers must report all of their patients who delivered during the reporting period, and all children born to them, in Columns 1a–1d. Included in this population will be any woman who has been a patient of the health center in the past and who tests positive for pregnancy by the health center, even if that woman is referred to another provider for some or all of her prenatal care.

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 reporting period including those who health center staff cared for and delivered and those who had some or all of their care provided by a referral provider. Include all women who had deliveries, regardless of the outcome, but do not include deliveries where you have no documentation that the delivery occurred (for example, for women who may have moved out of the area and/or who were otherwise lost to follow-up). This column collects data on “patients who delivered.” Even if the delivery is of twins or triplets, or is a still-birth, the health center is still to report only one delivery.

Birth Weight of Infants Born to Prenatal Care Patients Who Delivered During the Year (Columns 1b-1d)

Performance Measure: The performance measure is “Proportion of patients born to health center patients whose birth weight was below normal (less than 2500 grams).” Note that this is a “negative” measure. -- For this measure the higher the number of infants born with below normal birth weight, the worse the performance on the measure. While data are provided for each racial and ethnicity category, the performance measure looks only at the totals 20. The measure itself, which is not dependent on which category of failure to meet the measurement standard an infant falls in, is calculated as follows: •

Numerator: Number of children born with a birth weight of under 2500 grams (Line i, columns 1b + 1c)

Denominator: Number of children born (Line i, Columns 1b + 1c + 1d)

Report the total number of LIVE births during the reporting period for women who received prenatal care from the health center or a referral provider during the reporting period, according to the appropriate birth weight group. (Do not report still-births or miscarriages.) These columns collect data on “infants born.” If the delivery is of twins or triplets, the health center will report the birth weight of the two or three children separately. NOTE: Health centers must report birth weights for live children of all women who were in their prenatal care program or who were referred for care, and who delivered during the reporting

20

However, during the review of the UDS report, reviewers will question unusually high or low birth weights for individual race or ethnicity categories.

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period. Data are reported regardless of whether the health center did the delivery themselves, referred the delivery to another provider, or the woman transferred to another provider on her own. Follow-up on all patients is required. The number of deliveries reported in Column 1a will normally not be the same as the total number of infants reported in Columns 1b–1d because of multiple births and still births. Very Low Birth Weight (Column 1b) Report the total number of live children whose weight at birth was less than 1500 grams. Be careful not to confuse pounds and ounces for grams when reporting this number. Low Birth Weight (Column 1c) Report the total number of live children whose weight at birth was 1500 grams through 2499 grams. Be careful not to confuse pounds and ounces for grams when reporting this number. Normal Birth Weight (Column 1d) Report the total number of live children whose weight at birth was equal to or greater than 2500 grams. Be careful not to confuse pounds and ounces for grams when reporting this number.

Race and Ethnicity of Mothers and Infants Born to Prenatal Care Patients Who Delivered During the Year (Lines 1a - i)

Women (column 1a) and children (columns 1b, 1c and 1d) are separately reported by their race and ethnicity. Race and ethnicity of mothers should be obtained from and be consistent with the information on their patient registration forms. Race and ethnicity of children will be obtained from their registration forms, from their birth certificates, or from their parent.

Hypertension by Race and Hispanic/Latino Ethnicity, Section B (Columns 2a-2c) In this section, health centers report on findings from their reviews of current hypertensive patients, i.e., age appropriate patients who had at least two medical visits during the reporting period who have been diagnosed with hypertension at some point while they were a patient at the health center.

Data for this section may be obtained from an audit of charts selected through a process of scientific random sampling or through the use of Electronic Health Records whose templates or search parameters permit the recovery of a minimum of 80% of the records of the patients which fit the measurement profile. If a health center’s EHR is only able to provide data for a subset of Column A, it must be greater than or equal to 80% of column A and must not be restricted by any variable related to the test measure. For example, the health center may not use a separate “chronic disease tracking system” that is restricted to patients enrolled in their hypertension treatment program. In the event that fewer than 70 patients meet the criteria and are reported in Column A, the numbers in Column B must be the same as in Column A. Very specific definitions are to be used in order to identify the universe from which the sample will be drawn. These are described in detail below and must be carefully followed to avoid misreporting findings. Section B of Table 7 reports on all health center adult patients, who are 18 to 85 years of age (i.e., prior to 85th birthday), who have been diagnosed as hypertensive at any time before June 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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30, of the measurement year and who have been seen in the health center for medical visits at least twice during the reporting year. (The diagnosis may have first been made in a year prior to the measurement year or at the last visit of the year or at any time in between.) Performance Measure: The performance measure is “Proportion of patients born between January 1, 1931, and December 31, 1997, with diagnosed hypertension (HTN) whose blood pressure (BP) was less than 140/90 (adequate control) at the time of the last reading.” (NOTE: Many health centers use a different measure for their quality assurance process for their diabetic or dialysis patients or for older patients. This may well be appropriate, but for the purposes of UDS reporting, BP less than 140/90 measure must be used.) This is calculated as follows: •

Numerator: Number of patients in the denominator whose last systolic blood pressure measurement was less than 140 mm Hg and whose last diastolic blood pressure was less than 90 mm Hg

Denominator: All patients 18 to 85 years of age as of December 31, of the measurement year: o

With a diagnosis of hypertension (HTN), and

o

Who were first diagnosed by the health center as hypertensive at some point before June 30, of the measurement year, and

o

Who have been seen for medical visits at least twice during the reporting year

Total Patients Aged 18 to 85 with Hypertension, Column 2a Criteria: Enter the total number of patients by race and Hispanic/Latino ethnicity who meet all of the following criteria: •

Were born between January 1, 1931, and December 31, 1997, and

Have been seen at least twice during the reporting year for any reportable medical visit, and

Have been diagnosed with hypertension (HTN) before June 30, of the measurement year as evidenced by an ICD-9 code of 401.xx - 405.xx or ICD-10 code of I10- thru I15-. The diagnosis and notation of hypertension may appear during or prior to 2015.

Blood pressure readings (BP) that are self-reported by the patient such as when a patient calls in a blood pressure from home are generally not eligible unless a clinical management decision is made using that reading. If the patient is equipped with reliable technology and the provider is confident that the reading is reliable such that the provider is recording the automated BP reading and making prescription change or other decisions based on those readings, the health center can use the measurement. Exclusions: Pregnant patients, patients with end state renal disease (ESRD) Number of Charts Sampled or EHR Total, Column 2b Enter the total number of hypertensive health center patients by race and Hispanic/Latino ethnicity (Column 2a) included in the universe for whom data have been reviewed. This will either be a minimum of 80% or more of the patients who fit the criteria or a scientifically drawn sample of 70 patients drawn from all patients who fit the criteria.

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If a sample is to be used it must be a sample of 70 and must be drawn from the entire universe identified in Column 2a. 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 that result in oversampling some group of patients. The sampling method is described in Appendix C. If an EHR is present, it may be used in lieu of a chart review of a sample of charts if and only if: •

The EHR includes at least 80% of the clinic patients between the ages of 18 and 85, with diagnosed hypertension, regardless of whether or not they were specifically treated for hypertension.

Blood pressure is regularly recorded in the EHR for all patients.

The EHR has been in place throughout the reporting year.

If the EHR is to be used, the number in Column 2b will be a value no less than 80% of patients reported in Column 2a. NOTE: Health centers who have I2I-Track, PC-DEMS, PECS, or other disease tracking systems may use them to report the universe only if it can be limited to a calendar year report and only if it includes all required data elements, i.e., it includes data for the required time frame for all hypertensive patients from all service sites. In the event that fewer than 70 patients meet the criteria and are reported in Column A, the number in Column B must be the same as in Column A. Patients with Controlled Blood Pressure, Column 2c Hypertensive patients born between January 1, 1931, and December 31, 1997, whose charts have been reviewed (those identified in Column 2b) whose systolic blood pressure measurement was less than 140 mm Hg and whose diastolic blood pressure was less than 90 mm Hg at the time of their last measurement in 2014, are reported in Column 2c by race and Hispanic/Latino ethnicity. (Patients who have not had their blood pressure tested during the reporting year will be considered to have failed the performance measure. They are counted in Columns 2a and 2b, but not in Column 2c.) Important Notes about Race and Hispanic/Latino Ethnicity Numbers Comparisons are made between the universe reported on Table 7, Column 2a, and the data reported on Table 3B. Under no circ*mstances may a health center report more hypertensive Hispanic/Latinos or more hypertensive patients of any given race in Column 2a than are reported for that race or for the Hispanic/Latino ethnic group on Table 3B. Under most circ*mstances persons with no reported race and no reported ethnicity (Row h) will be relatively small. Use Row h only if, when you ask patients their race and whether or not they are Hispanic/Latino, they refuse to answer both questions. Those who do provide their race, but do not check that they are Hispanic/Latino on an intake form should be considered nonHispanic/Latino

Diabetes by Race and Hispanic/Latino Ethnicity, Section C (Columns 3a-3f)

In this section, health centers report on findings from their reviews of current patients with diabetes (i.e., patients who had at least two medical visits during the reporting period and who have been diagnosed with diabetes at some point while they were patients at the health center). Data for this section may be obtained from an audit of charts selected through a process of scientific random sampling or through the use of Electronic Health Records whose templates or 2015 UDS Manual—September 3, 2015 V 1.0 OMB Number: 0915-0193, Expiration Date: 02/28/2018

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search parameters permit the recovery of a minimum of 80% of the records of the patients which fit the measurement profile. Very specific definitions are to be used in order to identify the universe from which the sample will be drawn. These are described in detail below and must be carefully followed to avoid misreporting findings. This section of Table 7 reports on all health center patients 18 to 75 (i.e., prior to 75th birthday), who have been diagnosed as diabetic at some point during their time as patients at the health center. Performance Measure: The performance measure is “Proportion of adult patients born between January 1, 1941, and December 31, 1997, with a diagnosis of Type I or Type II diabetes, whose most recent hemoglobin A1c (HbA1c) during the measurement year was greater than 9%, or was missing a result, or if an HbA1c test was not done during the measurement year.” Health centers now report results in two categories: less than 8% and greater than 9%. Note that this is a “negative” measure. For this measure, the lower the number of adult diabetics with poor diabetes control, the better the performance on the measure. While data are provided for each race and ethnicity category, the performance measure looks only at the totals. The measure itself is calculated as follows: •

Numerator: Number of adult patients whose most recent hemoglobin A1c level during the measurement year is > 9% or who had no test during the year among those patients included in the denominator

Denominator: Number of adult patients aged 18 to 75, as of December 31, of the measurement year: o

With a diagnosis of Type I or II diabetes, and

o

Who have been seen in the clinic for medical visits at least twice during the reporting year, and

o

Do not meet any of the exclusion criteria

Total Patients Aged 18 to 75 with Type I or II Diabetes, Column 3a Criteria: Enter the number of adult patients by race and Hispanic/Latino ethnicity who meet the following criteria: •

Were born between January 1, 1941, and December 31,1997, and

Have been seen at least twice for medical care during the reporting year, and

Have a diagnosis of diabetes. It does not matter if diabetes was treated or is currently being treated or when the diagnosis was made. The notation of diabetes may appear during or prior to the 2015 measurement year. To confirm the diagnosis of diabetes, one of the following must be found in the medical record: o

ICD-9-CM Codes 250.xx or 648.0x or ICD-10 Codes E10-, E11- O24- (Excludes E28.2, E09-, E16.4, E16.8, O99.81, T38.0xxA)

o

Diabetic patients may also be identified from pharmacy data (those who were dispensed insulin or oral hypoglycemics/antihyperglycemics).

o

Note that unlike the hypertension measure, the diabetes measure calls for reporting on all diabetic patients regardless of when they were first diagnosed. It

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specifically does not make use of the June 30 date used to identify hypertensive patients. Exclusions: Exclude any patients with a diagnosis of polycystic ovaries (ICD-9 code 256.4 or ICD-10 code E28.2) that do not have two face-to-face visits with the diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year 21. Note that patients with gestational diabetes (ICD-9 code 648.8x or ICD-10 code O99.81) or steroidinduced diabetes (ICD-9 code 962.0, 249.xx, or 251.8 or ICD-10 code E16.4, E16.8) reported during the measurement year are not to be included. Number of Charts Sampled or EHR Total, Column 3b Enter the total number of diabetic health center patients by race and Hispanic/Latino ethnicity included in the universe (Column 3a) for whom data have been reviewed. This will either be a minimum of 80% or more of the patients who fit the criteria, or a scientifically drawn sample of 70 from all patients who fit the criteria (using the methodology described in Appendix C). If a sample is to be used it must be a sample of 70 and must be drawn from the entire patient population who fit the criteria (the universe reported in Column 3a). 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 that result in oversampling some group of patients. If an EHR is present, it may be used in lieu of a chart review of a sample of charts if and only if: •

The EHR includes at least 80% of all diabetic patients seen within the measurement year and can exclude from the universe those not seen during the measurement year,

Every item in the criteria is regularly recorded for all patients, and

The EHR has been in place throughout the performance year, and ideally for at least 3 years to permit identification of all diabetic patients.

If a health center’s EHR is only able to provide data for a subset of Column 3a, it must be greater than or equal to 80% of column 3a and must not be restricted by any variable related to the test measure. For example, the health center may not use a separate “chronic disease tracking system” that is restricted to patients enrolled in their diabetes treatment program. In the event that fewer than 70 patients meet the criteria and are reported in Column 3a, the numbers in Column 3b must be the same as in Column 3a. Reported Hemoglobin A1c Levels, Columns 3d1 and 3f For this report, the last hemoglobin A1c (HbA1c) level taken in the measurement year as documented through laboratory data or medical record review, is reported. If there is no record of a HbA1c level being obtained during the measurement year, the chart will be reported in Column 3f: “greater than 9.0% or no test during the year.” Patients with no test during the measurement year are included as non-compliant along with those who have poor HbA1c control. Note that 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.

21

If a search is made for pharmaceuticals that are used to treat diabetes, a person with these various conditions might be identified in error—hence this exclusion. If no search is done for pharmacy identification of patients, this can be ignored.

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Patients with HbA1c < 8% (Column 3d1): Number of patients included in Column 3b whose most recent HbA1c was less than 8%

Patients with HbA1c > 9% or No Test During Year (Column 3f): Number of patients included in Column 3b whose most recent HbA1c was greater than 9% and patients who did not receive an HbA1c test during the reporting year or whose test result is missing

Note that patients with HbA1c levels equal to or greater than 8% and less than or equal to 9% will not be reported beginning in CY 2015. That means that the two “results” columns (3d1 and 3f) will not equal the total records reviewed (column 3b).Important Notes about Race and Hispanic/Latino Ethnicity Numbers Comparisons are made between the universe reported on Table 7, Column 3a and the data reported on Table 3B. Under no circ*mstances may a health center report more diabetic Hispanic/Latinos or more patients from any given race reported in Column 3a than are reported for that race or for the Hispanic/Latino ethnic group on Table 3B. Under most circ*mstances persons with no reported race and no reported ethnicity (Row h) will be relatively small. Use Row h only if, when you ask patients their race and whether or not they are Hispanic/Latino, they refuse to answer both questions. Those who do provide their race, but do not check that they are Hispanic/Latino on an intake form should be considered nonHispanic/Latino.

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Questions and Answers for Table 7 1. Are there any changes to the table this year? Yes. Beginning with data from 2015, the number of categories for reporting diabetic HbA1c has been reduced. Only the HbA1c categories of “less than 8%” (Column d1) and “greater than 9% or No Test During the Year” (Column 3f) are reported. In addition, as with Tables 6A and 6B, use of both ICD-9 and ICD-10 codes will apply to identify patients with specific diagnosis. Careful attention is required to ensure that patients are only counted once with the condition although both ICD-9 and ICD-10 codes may both be used to help identify a patient with specific diagnosis. Also, if a health center’s EHR is only able to provide data for a subset of Column A, it must be greater than or equal to 80% of Column A and must not be restricted by any variable related to the test measure. In the event that fewer than 70 patients meet the criteria and are reported in Column A, the number in Column B must be the same as in Column A. 2. When would we use Row h: Unreported/Refused to Report race and ethnicity? Row h will be used only in those instances where patients refuse to provide their race and refuse to state whether or not they are Hispanic/Latino. Patients, who provide a race but do not answer affirmatively to a question about Hispanic/Latino ethnicity, are to be classified as Non-Hispanic/Latino and reported on the appropriate race line, Line 2a–2g. Patients who indicate they are Hispanic/Latino, but do not provide a race are reported on Line 1g. 3. Data are requested by race and Hispanic/Latino ethnicity. How are these to be coded? Race and Hispanic/Latino ethnicity are coded on this table in the exact same manner that is used for coding on Table 3B. Refer to instructions for Table 3B for further information. Note that if the race and/or ethnicity in the patient’s medical chart is different than that reported in the registration process it will result in errors. Care should be taken to ensure that the same information is recorded in both data sources. 4. Are patients with diabetes required to bring to the health center documentation of HbA1c tests received from outside the health center? Health centers should document all HbA1c tests by contacting providers of tests directly in order to obtain documentation by FAX, or by requesting health center patients to mail a copy of test results, or through other appropriate means. Health center patients should not be requested to return to the center merely to provide test documentation, however failure to document results means that the patient must be reported as not meeting the measurement standard. 5. We want to use these reviews to compare our sites and our providers to one another. As a result, we would like to use a larger universe. Is this permitted? No. First, all health centers using a sample must use 70 random charts. This facilitates the development of state, national, and other roll-up reports. Second, and perhaps more important, any change in the sample size as described would bias the sample and provide distortions in the data set. A health center may draw a larger random sample and use only the first 70 for the UDS, but the larger sample must be a random sample of the entire organization—it may not oversample specific sites or providers to facilitate internal QI activities.

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6. In Section A, Deliveries and Birth Outcomes, should the race and ethnicity reported for the mother be the same for the baby? Not necessarily. Report the race and ethnicity of the mother (Column 1a) separately from the child (Column 1b, 1c, or 1d). The babies’ race and ethnicity may be different from the mother and would be reported as such. 7. How do we report miscarriages and pregnancy terminations? All pregnant women in your (direct or referral) prenatal care program are reported on Table 6B, but only those women who deliver are reported on Table 7. We do, however, consider a still-birth to be a delivery for purposes of counting women in column 1a, but no child is reported in columns 1b, 1c, or 1d.

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Table 7: Health Outcomes and Disparities Reporting Period: January 1, 2015 through December 31, 2015

Section A: Deliveries and Birth Weight by Race and Hispanic/Latino Ethnicity Line 0 2 Line #

1a 1b1 1b2 1c 1d 1e 1f 1g

2a 2b1 2b2 2c 2d 2e 2f 2g

h i

Description HIV Positive Pregnant Women Deliveries Performed by Health Center’s Providers Prenatal Care Patients Who Race and Ethnicity Delivered During the Year (1a) Hispanic/Latino 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/Latino Non-Hispanic/Latino 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/Latino Unreported/Refused to Report Ethnicity Unreported/Refused to Report Race and Ethnicity Total

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Patients

Live Births:

[PDF] Bureau of Primary Health Care. Reporting Instructions for Health Centers - Free Download PDF (2024)

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