The guidance below responds to common questions regarding UDS reporting impacted by COVID-19.
Visits and Patients
If health centers increase virtual visit capabilities during spikes in COVID-19 cases, how are these visits and patients reported on the UDS?
- Report virtual visits on Table 5 in Column b2 (Virtual Visits, shown below). These visits must meet the criteria for a UDS visit (PDF - 189 KB) (documented encounter in the patient health record between a licensed or credentialed provider and a patient in which the provider exercises independent, professional judgment in providing in-scope services). Additionally, virtual visits must be coded as such in the health center’s health information technology or electronic health record system.
Note: Practitioner-to-practitioner consultation services are not countable as a UDS visit.
| Line | Personnel by Major Service Category | FTEs (a) |
Clinic Visits (b) |
Virtual Visits (b2) |
Patients (c) |
|---|---|---|---|---|---|
| 1 | Family Physicians | ||||
| 2 | General Practitioners | ||||
| 3 | Internists |
*Excerpt from Table 5
- Count patients throughout the UDS (demographics, services, clinical, and financial sections) when their visits qualify as a virtual visit, even if the visit is the first or only visit for the patient during the reporting period. For further guidance, refer to the UDS Virtual Visit resource guide (PDF - 164 KB).
- A UDS countable virtual visit must use live (synchronous, real-time) video connection between a provider and a patient (e.g., “FaceTime”) and two-way interactive audio technology (e.g., telephone). For the purpose of UDS reporting, store-and-forward (asynchronous, not real-time) or the electronic transmission of medical information, such as digital images, documents, and pre-recorded videos is not a countable UDS virtual visit.
- Virtual check-ins are used to determine whether an established patient requires a visit, and e-visits and portal communications with established patients would not count for UDS reporting purposes.
Can the Place of Service 50 modifier be used to identify virtual visits?
- Codes, such as place of service codes, add more information about a visit. Place of service code “50” should not be used to identify a virtual visit, as it only identifies the location as a federally qualified health center. It is more important that this underlying service code be used appropriately. It is recommended that the place of service code “02” be used for telehealth services.
Should individuals who receive a COVID-19 test or screening during the reporting year be reported on the UDS?
- If an individual is screened or tested (i.e., a specimen is collected or a series of questions asked to assess condition) for COVID-19 and no treatment or examination is typical with evaluation and management services (i.e., assessment of health status, examination, medical decision making) provided by the health center during the reporting year then this individual and encounter are not counted anywhere in the UDS (see also page 21 of the 2024 UDS Manual (PDF - 2 MB) for services and individuals not reported).
- The Centers for Medicare & Medicaid Services’ (CMS) Evaluation and Management Services Guide (PDF - 1004 KB) is a valuable resource for learning about the general principles of evaluation and management documentation, including the level and complexity of the service provided. Note: Practitioner to practitioner consultation services are not countable as a UDS visit.
- If, during the reporting year, the health center provides an individual with additional services (either before or after this service) that meet the countable visit criteria mentioned above (see also page 18 of the 2024 UDS Manual (PDF - 2 MB)), that individual may be considered a patient for UDS reporting. The patient characteristics, their visits, and associated services and care would be reported throughout the UDS Report.
Staffing
On the UDS Table 5, should possible staffing changes experienced by health centers be reported (e.g., staff furloughed, laid off, and out on Family and Medical Leave Act (FMLA))?
- Health centers should calculate and report any number of staff full-time equivalent (FTE) on Table 5 that the health center is paying for or incurring costs for during the calendar year, even if the personnel is not working (e.g., seeing patients) in that time.
- If health center personnel were laid off or furloughed during the calendar year, any portion of the year when they were not employed or paid by the health center should not be included in the FTE reported in Table 5.
- If health center personnel were out of work under FMLA during the calendar year, any portion of the year when a staff person was not working and not compensated should not be included in the FTE reported in Table 5.
- If the health center employed new personnel during the calendar year and the personnel provided in-scope activities, then their FTE should be calculated and reported in Table 5 based on the time worked and compensated during the year (see also page 55 of the 2024 UDS Manual (PDF - 2 MB) for Table 5 FTE reporting instructions).
- If volunteer staff provided in-scope services at a health center during the calendar year, then the volunteer time should be calculated and reported as FTE on Table 5 (see also page 185 of the 2024 UDS Manual (PDF - 2 MB) for reporting instructions on services provided by volunteer providers).
COVID-19 Tests, Diagnoses, and Vaccines
Which Table 6A lines capture data on COVID-19 testing, vaccines, and diagnosis?
- Line 4c (Novel coronavirus (SARS-CoV-2) disease)
- Line 4d (Post COVID-19 condition)
- Line 6a (Acute respiratory illness due to novel coronavirus (SARS-CoV-2) disease)
- Line 21c (Novel coronavirus (SARS-CoV-2) diagnostic test)
- Line 21d (Novel coronavirus (SARS-CoV-2) antibody test)
- Line 24b (Coronavirus (SARS-CoV-2) vaccine)
Table 6A, Line 6a, Acute respiratory illness due to novel coronavirus (SARS-CoV-2) disease, includes a note that states, “count codes listed only when U07.1 is also present.” To be counted on Line 6a, does the International Classification of Diseases, Tenth Revision (ICD-10) code U07.1 (COVID-19) need to be included in the same visit as the acute respiratory illness diagnosis-coded visit?
- The COVID-19 diagnosis code, U07.1, needs to be associated with the acute respiratory illness visit to mean that the service visit for acute respiratory illness was due to the novel coronavirus. See the 2024 Table 6A Code Changes (PDF - 218 KB) resource for the calendar year’s updates.
Health centers cannot always collect Current Procedural Terminology (CPT) codes for COVID-19 testing. Can lab codes, rather than the CPT codes listed in the manual, be used to report COVID-19 testing in Table 6A?
- If a lab code (e.g., Logical Observation Identifiers Names and Codes (LOINC) code) is specifically capturing the intended test and reflects that it is administered/completed (not just referred), then that code could be used. A test can be counted if it is: 1) performed by the health center, 2) paid for by the health center, but not performed by the health center, or 3) whose results are returned to the health center provider to evaluate and provide results to the patient, but not performed by the health center or paid for by the health center.
Clinical Quality Reporting
New health center protocols and workflows have changed the provision of care in response to COVID-19, and procedures, documentation, and follow-up will be affected. How will UDS clinical quality measure performance be considered for UDS reporting, especially if compliance rates suffer?
- BPHC recognizes the essential work (providing tests and treating those directly affected by the virus) performed by health centers during and following a COVID-19 spike in cases while implementing steps to continue providing routine, preventive, and chronic disease care to patients.
- There are steps that health centers can take to meet compliance with UDS clinical measure reporting. While some care must happen in person to meet the measurement standard, some care can be provided virtually. Please refer to the Telehealth Impact on UDS Clinical Measure Reporting (PDF - 227 KB) handout to see how virtual visits impact specific measure criteria.
- Document as much information in your systems as possible. Additionally, during the UDS data reporting and review period, health centers should document the impacts in UDS table validation comment fields before submission and work with their UDS Reviewer post-submission to help explain any changes resulting from the pandemic.
Can patient-reported vitals (e.g., blood pressure readings, height, and weight) obtained during a virtual visit count as meeting the measurement standard of specific UDS-reported clinical quality measures that require these? Can other services, tests, or procedures required to meet the measurement standard be done via telehealth?
- Self-attestation is not accepted for clinical measures that require these vitals. The specified measure steward defines each electronic clinical quality measure (eCQM), and the UDS Report aligns with their instructions.
- The measure stewards and CMS have provided guidance (PDF - 243 KB) and decisions for inclusion (or removal) of telehealth (virtual) in the evaluation of each component (denominator, exclusion, numerator) of the eCQM. Please refer to the Telehealth Impact on UDS Clinical Measure Reporting (PDF - 227 KB) for specific guidance on each UDS-reported clinical measure.
In Table 7, the Controlling High Blood Pressure measure, what is the guidance on remote patient monitoring related to virtual visits? How does remote patient monitoring differ from patient self-reporting?
- Only blood pressure readings performed by a clinician or care team member by a remote monitoring device are acceptable to meet the Controlling High Blood Pressure measurement standard, as specified by the measure steward (CMS165v11). This includes blood pressures taken in person by a clinician and blood pressures measured remotely by electronic monitoring devices capable of transmitting the blood pressure data to the clinician. Blood pressure readings taken by a remote monitoring device and conveyed by the patient to the clinician are also acceptable.
- The device used must have the capacity to capture, store, and transfer the reading taken by the patient, be observed by the clinician or member of the care team and be recorded in the patient’s chart at the health center. This is not the same as a patient providing this information to the provider (e.g., verbally or by entering the result into a patient portal), which would not meet the measurement standard.
Revenue
Where should health centers report COVID-19-related revenue on the UDS Report?
- Several lines on the revenue tables (Tables 9D and 9E) capture COVID-19-related revenue:
- Table 9E, Lines 1l through 1p: COVID-19 Supplemental Funding to reflect the grant amounts drawn down from BPHC activity codes (e.g., H8C, H8D, ECT, ECV) or other COVID-19-related funding from BPHC.
- Table 9E, Line 3b: Provider Relief Fund to reflect funds received through the U.S. Department of Health and Human Services (HHS) to relieve eligible providers for health care-related expenses or lost revenue attributable to coronavirus.
If a health center does not spend the provider relief funds it received, should it still report these funds (the full amount) on Table 9E?
- On Table 9E, health centers should only report the amount drawn down/cash received. If awarded Provider Relief Funds were not spent during the calendar year, report $0.