This blog was initially published in 2017. It has been updated based on changes that have been made to the UDS tables since then.
Before we know it, UDS season will be upon us. In preparation, this article details how each of the UDS tables is calculated within DRVS. Comprehending what data are being used in each table is the key to understanding the information in the DRVS UDS tables.
UDS Zip Code Table
The UDS Zip Code table is a count of the CHC’s patients that had a Face to Face (FTF) visit with a provider that has independent judgment during the reporting period and/or a telehealth encounter using interactive, synchronous audio and/or video telecommunication systems that permit real-time communication between the provider and a patient. These UDS FTF visits are identified using a list of CPT codes or by encounter types. During the CHC’s implementation process, one of these methods was chosen. If CPTs were chosen, a list of CPTs to be counted was provided to Azara. This list is different for every CHC because of the different types of services offered (i.e. dentistry, substance abuse, optometry). If the encounter type was chosen, the field contains a description of the type of visit (i.e. Office Visit, OB Visit, BH Visit.) At least once a year, mapping admin should be used to determine if any new CPTs/encounter types were added that should be counted as FTF. This section of mapping admin is read-only so changes must be done via a support ticket.
There is a new Telehealth Encounter section in mapping admin. Telehealth CPTs (G2012, G0071, 98969, 99441, 99442, 99443, 99444) & CPT modifiers (95, GT) will automatically count toward virtual visits. Mapping admin can be used to identify virtual visits by encounter type.
The term UDS Qualifying Encounter will be used throughout this document to indicate the patient had at least one FTF visit or one Telehealth Encounter during the period.
Dental visits will be included in the counts if your center offers dental services and the required information is in your EHR. If a dental practice management system is used (i.e. Dentrix), it is important to understand the flow of data into the EHR. If appointments, encounters, and charges flow into the EHR for dental encounters, all data will flow into DRVS and the dental visits will be counted. If billing is done in the EPM by using appointments and charges only, the DRVS connector needs to be told to cover this situation. All CDT codes associated with a UDS qualifying dental visit also should have been provided to Azara.
Have you noticed the Google Map at the bottom of the Zip Code Table that shows where the zip codes on the table are located? The count is the number of zip codes, not the number of patients in each zip code. Some centers have outliers. They may include snowbirds, patients who live in multiple states or patients who live in one state and work for periods of time in another state.
UDS Tables 3a & 3b - Demographics
Like the Zip Code Table, Tables 3a & 3b also contain counts of the CHC’s patients that had a UDS qualifying visit with a provider that has independent judgment during the reporting period. Each patient is only counted once per category.
In Table 3a, the patient’s age is calculated as of June 30th of the reporting period.
Race, Ethnicity, Language, Sexual Orientation & Gender Identity were all mapped during the CHC’s implementation. The mappings for each category can be found in the DRVS Mapping Administration. The CHC should confirm that all values were mapped and mapped correctly.
The UDS manual provides guidance for mapping Sexual Orientation and Gender Identity when it has not been collected. Sexual Orientation should be mapped to “Don’t know”. Gender Identity should be mapped to “Other.” When DRVS does not have a value, it will display as NULL in mapping admin.
UDS Table 4 – Patient Characteristics
Table 4 also contains counts of the CHC’s patients that had a UDS qualifying visit with a provider that has independent judgment during the reporting period. Each patient is only counted once per category.
Income as Percent of Poverty is calculated using family size and income. There are two ways a patient would be included in the Suspected Bad Data counts. If the family size or income or both contains non-numeric data, it would be suspected bad data. The other way is if the income is less than 5% or greater than 200% of the poverty line. Patients who have a 0 in their income fields are not included in the suspected bad data. If a patient has no value for family size and/or income, they would be counted in the Unknown/Unrecorded category.
DRVS used to capture family size and income as data fields on the patient record. This means for every patient there was only one value for family size and one value for income. DRVS now has the ability to track both values over time. Most centers were already converted to this method. You can verify that your CHC was converted by looking in the Maintenance (Structured Clinical Data) section of Mapping Admin. There are two mappings – Household Income PRAPARE and Household Size PRAPARE. These values can be mapped even if the CHC does not have the SDOH module in DRVS. If these values were not mapped, DRVS is using the values on the patient’s record, and the practice needs to be converted to the new calculation method.
If the CHC does not track family size and income but does track the federal poverty level, DRVS has a new place to map this data. Contact Azara Support to have it mapped.
Historically, the Principal Third Party Medical Insurance has been the latest active primary payer for the patient during the period. DRVS offers a new calculation based on the active insurance at the time of the latest encounter. To switch methods, open a ticket with Azara Support. The mappings for financial class can be viewed in DRVS Mapping Administration.
Using the original calculation, patients counted under None/Uninsured have a primary payer that has an uninsured financial class. Patients counted under unknown, do not have a primary payer or the financial class on their primary payer is not mapped.
When the new calculation is used, if the patient did not have any insurance records at the time of the encounter, they are counted under uninsured because it was the most recent insurance status in an encounter. If they have an insurance record but there is no financial class, it is counted under unknown.
A patient is considered of Dual Eligible (Medicare and Medicaid) status if they had two active insurance policies (one Medicare and one Medicaid) or if one of their insurance’s financial class was mapped to Dual Eligible Medicare and Medicaid.
The homeless status will indicate if a patient has been homeless at any time during the year. Prior to this year, homeless status was an attribute of the patient. DRVS can now track the patient’s homeless status over time to show patients who were homeless during a part of the year even if they are not now. To determine if your center’s homeless status is being tracked over time, look in the Maintenance (Structured Clinical Data) section of Mapping Admin. There will be mapping for UDS Homelessness Status. If there is no mapping, contact Azara Support to have it added. There is also a new mapping for homelessness this year – ‘Permanent Supportive Housing’.
Please note that Public Housing refers to patients at the health center that are part of a public housing program a short distance away from the center. Patients who have this living situation should not be confused with or documented as homeless. There is no mapping for this data, it is an attribute of the patient.
Migrant Status was mapped during the CHC’s implementation. The mappings can be found in the DRVS Mapping Administration. The CHC should confirm that all values have been mapped and that they were mapped correctly.
When locations were set up for your center, they were marked a school-based or non-school based. If the numbers look low, there may be a new school-based location. Azara Support will be happy to map any of these for you.
For Veteran status, there is a new section in mapping administration. All centers should map their values. If you do not have any values for veteran status and are capturing that information in your EHR, submit a support ticket to have it mapped.
UDS Table 5 – Staffing and Utilization
Table 5 also contains counts of the CHC’s patients that had a UDS qualifying visit with a provider that has independent judgment during the reporting period. Each patient is only counted once per category.
New this year is a column for virtual visits. Within mapping admin, there is a new section called Telehealth Encounter. It contains a list of encounter types that were done at the CHC in the past year. If your center is performing telehealth visits, update that encounter type to a ‘Y’. DRVS will also look at CPT codes to identify virtual visits as discussed above.
Staffing & Utilization is calculated based on the UDS Service Category associated with the Provider. Many centers use provider type & specialty for the UDS Service Category. Other centers have a specific field in their EHR that they use. Still others map based on the provider name alone. The UDS Service Category mappings can be viewed in DRVS Mapping Administration.
Zip Code Table & Tables 3a, 3b and 4 versus Table 5
The total patient count on Zip Code Table and Tables 3a, 3b and 4 should match. The total patient count on Table 5 will NOT match the other tables because patients may be double-counted if they see multiple service line providers – for example, a family medicine provider and a dentist. A patient is only allowed one visit per day per category (i.e. either medical, dental, behavioral health.)
UDS Table 6a – Selected Diagnoses & Services Rendered
Table 6a looks at encounters where a specific disease/condition was treated or when services were rendered at the CHC. DRVS uses problems/assessments entered during the period and/or billing data for that period.
Having a prior active diagnosis on the problem list does not count. For example, an HIV patient may have been diagnosed many years ago and has an encounter in the period for a sore throat. Their HIV is not accessed during the visit and there is no HIV diagnosis on the billing data. That visit would not count under HIV in 6a.
For services (i.e. mammograms, paps), DRVS only looks at the charges and the diagnoses on the charge.
DRVS no longer requires that a seasonal flu shot was given at a qualifying visit. This allows DRVS to count immunizations given during a nurse visit, however, a patient must have had a qualifying encounter previously in the reporting period.
A common question during UDS season is “My Tobacco Cessations measure is at 95%. Why is my smoke and tobacco use cessation counseling 0 on Table 6a?” The most common answer is that the providers are checking the counseling box but not billing for it. Advice to quit given by non-provider staff also satisfies the 6b Tobacco/Smoking Cessation measure, and would not be billed, and therefore, would not be reflected on 6a, even if credit is given on 6b.
UDS Table 6b – Quality of Care Measures
Sections A & B
Table 6b, sections A & B count pregnant patients who had a qualifying Primary Care visit at the center in the reporting period. The patient does not need to be receiving prenatal care at the CHC. See Table 7 for the methods used by DRVS to determine if a patient is pregnant.
The mother’s age is calculated as of June 30th of the reporting period.
Sections C - M
Sections C-M are calculated based on measure definitions. To see the measure definition, click on the next to the measure name.
There have been some recent changes to DRVS and/or measure specs that are worth mentioning.
Cervical Cancer Screening & Diabetes A1C > 9 or Untested –DRVS maps labs based on Logical Observation Identifiers Names and Codes (LOINC) or CPT codes as of the Sept 2019 release. This may affect your numbers if labs were incorrectly mapped, if they were not mapped at all or if the lab assigns incorrect LOINC codes. Lab mappings may be viewed in the lab results section of mapping admin. The method of mapping is shown in the mapped lab results value column. It will show LOINC, CPT or manual.
Childhood Immunization Status – This year DRVS was updated to automatically map immunizations based on CVX codes or the immunization name if a CVX code does not exist. The CDC's National Center of Immunization and Respiratory Diseases (NCIRD) developed and maintain the CVX (vaccine administered) code set. DRVS pulls the CVX code from your EHR. The automapping removes that requirement that someone maintains the mappings when new immunization names are added.
If your numbers declined this year, it may be because of rotavirus. CVX codes allow us to determine if the child has received a two-dose or a three-dose rotavirus immunization. If the child starts with a three-dose rotavirus immunization, all rotavirus immunizations must be of a three-dose variety. If they start with a two-dose rotavirus immunization, either a two or three-dose rotavirus will count to satisfy their rotavirus requirements. Complications arise if the rotavirus is unspecified (CVX 122). Without specificity, DRVS cannot tell if it is a two or three-dose. DRVS will it count as a 3 dose. We have adjusted the measure detail to help you identify which rotavirus immunizations the patients have received.
DRVS also now looks at antibody and titer labs to determine if the child needs the immunization.
Colorectal Cancer Screening – We have removed CPT codes for FIT/FOBTs from the colorectal cancer screening value set. We will now only include actual lab results.
Screening for Depression and Follow-Up Plan – This measure was updated this year. A PHQ-9 that was administered in response to a positive PHQ-2 and is also positive no longer meets the measurement standard for follow-up. If the PHQ-9 is negative, the patient will be in the numerator because the PHQ-9 will be taken as the screen. If the patient screened positive and a follow-up plan was documented, the patient will be in the numerator. If the provider enters depression into the problem list and the patient comes in again, they will now be excluded. For more information, see Heather Budd’s blog here.
Tobacco Use: Screening and Cessation – Azara updated this measure before last year’s UDS but the changes may not be fully understood. Cessation counseling must come on or after the latest positive smoking screening. If a patient is screened as a smoker and cessation counseling is done at that visit, the patient is in the numerator. If they come in again the next day, their tobacco status is recorded as yes but no cessation counseling is given, the patient is no longer in the numerator. It does not matter if the latest tobacco status is for smoking or oral tobacco. For more information, see LuAnn Kimker’s blog here .
Table 7
Birthweights
There are three methods that DRVS uses to determine if a patient has delivered in the current year.
- The most accurate is when a CHC uses the ‘ob case’ or ‘active pregnancy’ functionality within the EHR. When a patient becomes pregnant, a record is created in the EHR. All information about the pregnancy is recorded there. When the pregnancy ends the outcome is recorded and the pregnancy is closed. Using this method, DRVS does not have to sort through conflicting information. It also allows for a patient to have multiple pregnancies in a year and to track fetal demise. If your CHC uses this functionality within the EHR and your queries have not been converted to this method, contact Azara support.
- If your CHC captures the estimated date of conception (EDC) and the estimated date of delivery (EDD), DRVS uses this data to deduce the start and end date of the pregnancy. DRVS is creating a single ‘pregnancy’ record based on the data that it is receiving. If there is more than one pregnancy in the year (fetal demise or a pregnancy soon after live birth), calculations get complicated. DRVS calculates when the first pregnancy ended and the second pregnancy started. There may also be conflicting data in the EHR and DRVS will decide which of the values to use.
- When there is no EDC & EDD, DRVS looks for a delivery code and a birthweight record. With this method, a patient can have only one pregnancy per year and there is no way to track fetal demise. This method is the least accurate and is not used for many CHCs.
Hypertension BP
Patients must have had a UDS qualifying Primary Care encounter in the reporting period. The Hypertension diagnosis must have been active within the first six months of the year . The blood pressure is pulled from the Vitals section in the EHR.
A common question is “how come the 6a hypertension number does not match the table 7 hypertension number?”The definition of table 6a is visits in the year for HTN. The definition of Table 7 is patients with an active DX of HTN in the first six months of the year.
Diabetes A1C
Patients must have had a UDS qualifying Primary Care encounter in the reporting period and have a diabetes diagnosis. A1C is a lab. A1C mappings may be viewed in Mapping Admin; as a reminder, with the update to LOINC matching, labs in the Mapping Admin are now read-only.
Accessing Azara Support
The Azara support team is ready to assist you if questions about your data arise or if new workflows have been put in place that need to be mapped. There are several ways to submit a support ticket.
- Email – a ticket can be created by sending an email to support@azarahealthcare.com. Do not send PHI.
- DRVS screens have an envelope icon on the upper right-hand corner of the screen. This will initiate an email to support. Do not send PHI.
- Log into the Azara Support Portal – Tickets can be submitted, reviewed and updated via the portal. The support portal is secure. PHI may be uploaded to a ticket via the portal. There is also a knowledge base that has answers to common questions. https://jira.azarahealthcare.com/servicedesk.
For all tickets, supply as much information as possible. Indicate on which screen/measure the issue is, what filters were used, a detailed description of the problem, and provide a patient example.
If you are interested in hearing a webinar focused on UDS 2019 in DRVS, please plan to attend our webinar UDS 2019 Prep scheduled on October 24th from 3-4pm Eastern time featuring Greg Augustine and Heather Budd. DRVS users can find the registration information in DRVS Help.