Document Title: Uniform Data System Changes for Calendar Year 2021
Document Number: 2020-07
Date: October 21, 2020
To: Health Centers, Primary Care Associations, Primary Care Offices, and National Training and Technical Assistance Partners
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
- Childhood Immunization Status has been revised to align with CMS117v9.
- Cervical Cancer Screening has been revised to align with CMS124v9.
- Breast Cancer Screening has been revised to align with CMS125v9.
- Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents has been revised to align with CMS155v9.
- Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan has been revised to align with CMS69v9.
- Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention has been revised to align with CMS138v9.
- Statin Therapy for the Prevention and Treatment of Cardiovascular Disease has been revised to align with CMS347v4.
- Colorectal Cancer Screening has been revised to align with CMS130v9.
- HIV Screening has been revised to align with CMS349v3.
- Preventive Care and Screening: Screening for Depression and Follow-Up Plan has been revised to align with CMS2v10.
- Depression Remission at Twelve Months has been revised to align with CMS159v9.
- Controlling High Blood Pressure has been revised to align with CMS165v9.
- Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%) has been revised to align with CMS122v9.
B. Coronavirus Disease (COVID-19) UDS Data Elements:
- 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. - COVID-19 Funding 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. - 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
- ICD-10-CM (2020) – National Center for Health Statistics (NCHS)
- CPT (2020) – American Medical Association (AMA)
- Code on Dental Procedures and Nomenclature CDT Code (2020) – Dental Procedure Codes. American Dental Association (ADA)
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.)
- Primary care
- Oral health
- Behavioral health: Mental health
- Behavioral health: Substance use disorder
- Dermatology
- Chronic conditions
- Disaster management
- Consumer health education
- Provider-to-provider consultation
- Radiology
- Nutrition and dietary counseling
- Other (Please specify:)
b. No. If you did not have telemedicine services, please comment why. (Select all that apply.)
- Have not considered/unfamiliar with telehealth service options
- Policy barriers (Select all that apply)
- Lack of or limited reimbursement
- Credentialing, licensing, or privileging
- Privacy and security
- Other (Please specify: )
c. Inadequate broadband/ telecommunication service (Select all that apply)
- Cost of service
- Lack of infrastructure
- Other (Please specify: )
- Lack of funding for telehealth equipment
- Lack of training for telehealth services
- Not needed
- 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