2021 Uniform Data System (UDS) Program Assistance Letter (PAL)

Document Number: 2020-07

I. Background

This Program Assistance Letter (PAL) provides an overview of updates to the Health Resources and Services Administration’s (HRSA) calendar year (CY) 2021 Uniform Data System (UDS) to be reported by Health Center Program awardees and look-alikes in February 2022. Additional details regarding these updates will be expounded in the forthcoming  2021 UDS Manual.

II.  Updates for CY 2021 UDS Reporting

A. Update Quality of Care Measures to Align with E-CQMS: Tables 6B and 7

To support efforts across the federal government that standardize data collection and reduce reporting burden for entities participating in federal programs with data reporting mandates, the following UDS clinical quality measures have been aligned with the versions of the Centers for Medicare and Medicaid Services (CMS) electronic-specified clinical quality measures (eCQMs) designated for the 2021 reporting period.

Rationale: Data-driven quality improvement and full optimization of electronic health record (EHR) systems are strategic priorities for the Health Center Program. Clinical measure alignment across national programs decreases reporting burden and improves data standardization. Additionally, measure alignment and harmonization with other national quality programs such as the National Quality Forum (NQF) and the CMS Quality Payment Program (QPP), remains a federal priority. Hyperlinks to the Electronic Clinical Quality Improvement (eCQI) Resource Center have been included to provide additional details of the eCQMs. 

2021 UDS eCQMs

  1. Childhood Immunization Status has been revised to align with CMS117v9.
  2. Cervical Cancer Screening has been revised to align with CMS124v9.
  3. Breast Cancer Screening has been revised to align with CMS125v9.
  4. Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents has been revised to align with CMS155v9.
  5. Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan has been revised to align with CMS69v9.
  6. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention has been revised to align with CMS138v9.
  7. Statin Therapy for the Prevention and Treatment of Cardiovascular Disease has been revised to align with CMS347v4.
  8. Colorectal Cancer Screening has been revised to align with CMS130v9.
  9. HIV Screening has been revised to align with CMS349v3.
  10. Preventive Care and Screening: Screening for Depression and Follow-Up Plan has been revised to align with CMS2v10.
  11. Depression Remission at Twelve Months has been revised to align with CMS159v9.
  12. Controlling High Blood Pressure has been revised to align with CMS165v9.
  13. Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%) has been revised to align with CMS122v9.

B. Coronavirus Disease (COVID-19) UDS Data Elements:

  1. Testing and Diagnosis Codes in Table 6A
    In response to the COVID-19 pandemic, the 2020 UDS included COVID-19 Healthcare Common Procedural Coding System (HCPCS), Current Procedural Terminology (CPT), and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes to enable the collection of COVID-19 testing and treatment data at health centers. These codes, along with any other new pertinent ones, will be included in the 2021 UDS to continue informing HRSA and the Department of Health and Human Services (HHS) about the health centers’ COVID-19 testing and treatment capability.
  2. COVID-19 Ffunding LInes on Table 9D and 9E
    HRSA awarded supplemental funding, through various legislation, to support health centers in responding to the COVID-19 public health emergency (PHE). The 2020 UDS created new reporting lines to provide HRSA the flexibility to track all COVID-19 supplemental funding. These funding lines will be included in the 2021 UDS. In addition, any future COVID-19-related funding lines may be included in the 2021 UDS.
  3. COVID-19 Vaccination Question in Appendix E, Other Data Elements
    A question asking health centers how many COVID-19 vaccines were administered was included in the 2020 UDS and will also be included in the 2021 UDS. This data will inform HRSA about the health centers’ COVID-19 prevention capability.

III.   Contacts

For questions or comments regarding the updates to the CY 2021 UDS, contact the Office of Quality Improvement at OQIComments@hrsa.gov.

Sincerely

/S/

James Macrae
Associate Administrator

Table 6B: Quality of Care Measures

Reporting Period: January 1, 2021, through December 31, 2021

Prenatal Care Provided by Referral Only (Check if Yes)

Section A—Age Categories for Prenatal Care Patients: Demographic Characteristics of Prenatal Care Patients

Line Age Number of Patients (a)
1 Less than 15 years  
2 Ages 15-19  
3 Ages 20-24  
4 Ages 25-44  
5 Ages 45 and over  

Total Patients (Sum of Lines 1-5)

Section B—Early Entry into Prenatal Care

Line Early Entry into Prenatal Care Patients Having First Visit with Health Center (a) Patients Having First Visit with Another Provider (b)
7 First Trimester    
8 Second Trimester    
9 Third Trimester    

Section C—Childhood Immunization Status

Line Childhood Immunization Status Total Patients with 2nd Birthday (a) Total Patients with 2nd Birthday (a) Number of Patients Immunized (c)
10 Measure: Percentage of children 2 years of age who received age appropriate vaccines by their 2nd birthday      

Section D—Cervical and Breast Cancer Screening

Line Cervical Cancer Screening Total Female Patients
Aged 23 through 64 (a)
Number Charts Sampled or EHR Total (b) Number of Patients Tested (c)
11 Measure: Percentage of women 23–64 years of age who were screened for cervical cancer      

 

Line Breast Cancer Screening Total Female Patients
Aged 51 through 73 (a)
Number Charts Sampled or EHR Total (b) Number of Patients with Mammogram (c)
11a Measure: Percentage of women 51–73 years of age who had a mammogram to screen for breast cancer      

Section E—Weight Assessment and Counseling for Nutrition and Physical Activity of Children and Adolescents

Line Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Total Patients Aged 3 through 16 (a) Number Charts Sampled or EHR Total (b) Number of Patients with Counseling and BMI Documented (c)
12 Measure: Percentage of patients 3–16 years of age with a BMI percentile and counseling on nutrition and physical activity documented      

Section F—Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

Line Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan Total Patients Aged 18 and Older (a) Number Charts Sampled or EHR Total (b) Number of Patients with BMI Charted and Follow-Up Plan Documented as Appropriate (c)
13 Measure: Percentage of patients 18 years of age and older with (1) BMI documented and (2) follow-up plan documented if BMI is outside normal parameters      

Section G—Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Line Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Total Patients Aged 18 and Older (a) Number Charts Sampled or EHR Total (b) Number of Patients Assessed for Tobacco Use and Provided Intervention if a Tobacco User (c)
14a Measure: Percentage of patients aged 18 years of age and older who (1) were screened for tobacco use one or more times within 24 months, and (2) if identified to be a tobacco user received cessation counseling intervention      

Section H—Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

Line Statin Therapy for the Prevention and Treatment of Cardiovascular Disease Total Patients Aged 21 and Older at High Risk of Cardiovascular Events (a) Number Charts Sampled or EHR Total (b) Number of Patients Prescribed or On Statin Therapy (c)
17a Measure: Percentage of patients 21 years of age and older at high risk of cardiovascular events who were prescribed or were on statin therapy      

Section I—Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet

Line Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet Total Patients Aged 18 and Older with IVD Diagnosis or AMI, CABG, or PCI Procedure (a) Number Charts Sampled or EHR Total (b) Number of Patients with Documentation of Aspirin or Other
Antiplatelet Therapy (c)
18 Measure: Percentage of patients 18 years of age and older with a diagnosis of IVD or AMI, CABG, or PCI procedure with aspirin or another antiplatelet      

Section J—Colorectal Cancer Screening

Line Colorectal Cancer Screening Total Patients Aged 50 through 74 (a) Number Charts Sampled or EHR Total (b) Number of Patients with Appropriate Screening for Colorectal Cancer(c)
19 Measure: Percentage of patients 50 through 74 years of age who had appropriate screening for colorectal cancer      

Section K—HIV Measures

Line HIV Linkage to Care Total Patients First Diagnosed with HIV (a) Number Charts Sampled or EHR Total (b) Number of Patients Seen Within 30 Days of First Diagnosis of HIV (c)
20 Measure: Percentage of patients whose first-ever HIV diagnosis was made by health center staff between December 1 of the prior year and November 30 of the measurement year and who were seen for follow-up treatment within 30 days of that first-ever diagnosis      

 

Line HIV Screening Total Patients Aged 15 through 65 (a) Number Charts Sampled or EHR Total (b) Number of Patients Tested for HIV (c)
20a Measure: Percentage of patients 15 through 65 years of age who were tested for HIV when within age range      

Section L—Depression Measures

Line Preventive Care and Screening: Screening for Depression and Follow-Up Plan Total Patients Aged 12 and Older (a) Number Charts Sampled or EHR Total (b) Number of Patients Screened for Depression and Follow-Up Plan Documented as Appropriate (c)
21 Measure: Percentage of patients 12 years of age and older who were (1) screened for depression with a standardized tool and, if screening was positive, (2) had a follow-up plan documented      

 

Line Depression Remission at Twelve Months Total Patients Aged 12 and Older with Major Depression or Dysthymia (a) Number Charts Sampled or EHR Total (b) Number of Patients who Reached Remission (c)
21a Measure: Percentage of patients 12 years of age and older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event      

Section M—Dental Sealants for Children between 6–9 Years

Line Dental Sealants for Children between 6–9 Years Total Patients Aged 6 through 9 at Moderate to High Risk for Caries (a) Number Charts Sampled or EHR Total (b) Number of Patients with Sealants to First Molars (c)
22 Measure: Percentage of children 6 through 9 years of age at moderate to high risk of caries who received a sealant on a first permanent molar      

Excerpts of Table 6A: Selected Diagnoses and Services Rendered

Reporting Period: January 1, 2021, through December 31, 2021

Selected Diagnoses

Selected Infectious and Parasitic Diseases

Line Diagnostic Category Applicable ICD-10-CM Code Number of Visits by Diagnosis Regardless of Primacy (a) Number of
Patients with
Diagnosis (b)
1-2 Symptomatic/Asymptomatic human immunodeficiency virus (HIV) B20, B97.35, O98.7-, Z21    
3 Tuberculosis A15- through A19-, O98.0-    
4 Sexually transmitted infections A50- through A64-    
4a Hepatitis B B16.0 through B16.2, B16.9, B17.0, B18.0, B18.1, B19.1-, O98.4-    
4b Hepatitis C B17.1-, B18.2, B19.2-    
4c Novel coronavirus (SARS-CoV-2) disease U07.1    

Selected Diseases of the Respiratory System

Line Diagnostic Category Applicable ICD-10-CM Code Number of Visits by Diagnosis Regardless of Primacy (a) Number of
Patients with
Diagnosis (b)
5 Asthma J45-    
6 Chronic lower respiratory diseases J40 (count only when code U07.1 is not present), J41- through J44-, J47-    
6a Acute respiratory illness due to novel coronavirus (SARS-CoV-2) disease J12.89, J20.8, J40, J22, J98.8, J80 (count only when code U07.1 is present)    

Selected Other Medical Conditions

Line Diagnostic Category Applicable ICD-10-CM Code Number of Visits by Diagnosis Regardless of Primacy (a) Number of
Patients with
Diagnosis (b)
7 Abnormal breast findings, female C50.01-, C50.11-, C50.21-, C50.31-, C50.41-, C50.51-, C50.61-, C50.81-, C50.91-, C79.81, D05-, D48.6-, D49.3, N60-, N63-, R92-    
8 Abnormal cervical findings C53-, C79.82, D06-, R87.61-, R87.629, R87.810, R87.820    
9 Diabetes mellitus E08- through E13-, O24- (exclude O24.41-)    
10 Heart disease (selected) I01-, I02- (exclude I02.9), I20- through I25-, I27-, I28-, I30- through I52-    
11 Hypertension I10- through I16-, O10-, O11-    
12 Contact dermatitis and other eczema L23- through L25-, L30- (exclude L30.1, L30.3, L30.4, L30.5), L58-    
13 Dehydration E86-    
14 Exposure to heat or cold T33-, T34-, T67-, T68-, T69-, W92-, W93-    

Selected Services Rendered

Selected Diagnostic Tests/ Screening/Preventive Services

Line Service Category Applicable ICD-10-CM, CPT-4/II/PLA, or HCPCS Code Number of Visits (a) Number of
Patients (b)
21 HIV test CPT-4: 86689, 86701 through 86703, 87389 through 87391, 87534 through 87539, 87806    
21a Hepatitis B test CPT-4: 86704 through 86707, 87340, 87341, 87350    
21b Hepatitis C test CPT-4: 86803, 86804, 87520 through 87522    
21c Novel coronavirus (SARS-CoV-2) diagnostic test CPT-4: 87426, 87635
HCPCS: U0001, U0002, U0003, U0004
CPT PLA: 0202U, 0223U, 0225U
   
21d Novel coronavirus (SARS-CoV-2) antibody test CPT-4: 86328, 86408, 86409, 86769
CPT PLA: 0224U, 0226U
   
21e Pre-Exposure Prophylaxis (PrEP)-associated management of all PrEP patients CPT-4: 99401-99404
ICD-10: Z11.3, Z11.4, Z20.2, Z20.6, Z51.81, Z71.51, Z71.7, Z79.899
Limit to emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) or emtricitabine/tenofovir alafenamide (FTC/TAF) for PrEP
   

Sources of Codes

Note: “X” in a code denotes any number, including the absence of a number in that place. Dashes (-) in a code indicate that additional characters are required. ICD-10-CM codes all have at least four digits. These codes are not intended to reflect whether or not a code is billable. Instead, they are used to point out that other codes in the series are to be considered.

Excerpt of Table 9D: Patient-Related Revenue

Reporting Period: January 1, 2021, through December 31, 2021

Line Payer Category Full Charges This Period
(a)
Amount Collected This Period
(b)
Collection of Reconciliation/ Wraparound Current Year
(c1)
Collection of Reconciliation/ Wraparound Previous Years
(c2)
Collection of Other Payments:
P4P, Risk Pools, etc.
(c3)
Penalty/ Payback
(c4)
Adjustments
(d)
Sliding Fee Discounts
(e)
Bad Debt Write-Off
(f)
1 Medicaid Non-Managed Care                  
2a Medicaid Managed Care (capitated)                  
2b Medicaid Managed Care (fee-for-service)                  
3 Total Medicaid
(Sum of Lines 1 + 2a + 2b)
                 
4 Medicare Non-Managed Care                  
5a Medicare Managed Care (capitated)                  
5b Medicare Managed Care (fee-for-service)                  
6 Total Medicare
(Sum of Lines 4 + 5a + 5b)
                 
7 Other Public, including Non-Medicaid CHIP, Non-Managed Care                  
8a Other Public, including Non-Medicaid CHIP, Managed Care (capitated)                  
8b Other Public, including Non-Medicaid CHIP, Managed Care (fee-for-service)                  
8c Other Public, including COVID-19 Uninsured Program                  

Table 9E: Other Revenues

Reporting Period: January 1, 2020, through December 31, 2020

BPHC Grants (Enter Amount Drawn Down—Consistent with PMS 272)

Line Source Amount
(a)
1a Migrant Health Center  
1b Community Health Center  
1c Health Care for the Homeless  
1e Public Housing Primary Care  
1g Total Health Center (Sum of Lines 1a through 1e)  
1k Capital Development Grants, including School-Based Health Center Capital Grants  
1l Coronavirus Preparedness and Response Supplemental Appropriations Act (H8C)  
1m Coronavirus Aid, Relief, and Economic Security Act (CARES) (H8D)  
1n Expanding Capacity for Coronavirus Testing (ECT) (H8E and LAL ECT)  
1o Health and Economic Recovery Omnibus Emergency Solutions Act (HEROES)/ Health, Economic Assistance, Liability Protection and Schools Act (HEALS)  
1p Other COVID-19-Related Funding from BPHC (specify_______)  
1q Total COVID-19 Supplemental (Sum of Lines 1l through 1n)  
1 Total BPHC Grants
(Sum of Lines 1g + 1k + 1q)
 

Other Federal Grants

Line Source Amount
(a)
2 Ryan White Part C HIV Early Intervention  
3 Other Federal Grants (specify _______)  
3a Medicare and Medicaid EHR Incentive Payments for Eligible Providers  
3b Provider Relief Fund (specify _______)  
5 Total Other Federal Grants
(Sum of Lines 2 through 3b)
 

Non-Federal Grants or Contracts

Line Source Amount
(a)
6 State Government Grants and Contracts (specify_______)  
6a State/Local Indigent Care Programs (specify_______)  
7 Local Government Grants and Contracts (specify_______)  
8 Foundation/Private Grants and Contracts (specify_______)  
9 Total Non-Federal Grants and Contracts
(Sum of Lines 6 + 6a + 7 + 8)
 
10 Other Revenue (non-patient related revenue not reported elsewhere) (specify _______)  
11 Total Revenue (Sum of Lines 1 + 5 + 9 + 10)  

Excerpt of Appendix E: Other Data Elements

Reporting Period: January 1, 2021, through December 31, 2021

2a3. What primary telemedicine services were used at your organization? (Select all that apply.)

  1. Primary care
  2. Oral health
  3. Behavioral health: Mental health
  4. Behavioral health: Substance use disorder
  5. Dermatology
  6. Chronic conditions
  7. Disaster management
  8. Consumer health education
  9. Provider-to-provider consultation
  10. Radiology
  11. Nutrition and dietary counseling
  12. Other (Please specify:)

b. No. If you did not have telemedicine services, please comment why. (Select all that apply.)

  1. Have not considered/unfamiliar with telehealth service options
  2. Policy barriers (Select all that apply)
    1. Lack of or limited reimbursement
    2. Credentialing, licensing, or privileging
    3. Privacy and security
    4. Other (Please specify: )

c. Inadequate broadband/ telecommunication service (Select all that apply)

  1. Cost of service
  2. Lack of infrastructure
  3. Other (Please specify: )
    1. Lack of funding for telehealth equipment
    2. Lack of training for telehealth services
    3. Not needed
    4. Other (Please specify:)

3. Provide the number of all assists provided during the past year by all trained assisters (e.g., certified application counselor or equivalent) working on behalf of the health center (employees, contractors, or volunteers), regardless of the funding source that is supporting the assisters’ activities. Outreach and enrollment assists are defined as customizable education sessions about affordable health insurance coverage options (one-on-one or small group) and any other assistance provided by a health center assister to facilitate enrollment. Enter number of assists 

Note: Assists do not count as visits on the UDS tables.

4: How many patients received an FDA-approved COVID-19 vaccine during the calendar year at your organization? 

Note: Exclude vaccines administered to health center patients while participating in a clinical trial

Date Last Reviewed:  November 2020