Table 6A, Selected Diagnoses and Services Rendered; Table 6B, Quality of Care Indicators

This table reports data on selected diagnoses and services rendered. It is designed to provide information on diagnoses and services of greatest interest to BPHC using data maintained for billing purposes. As a subset of diagnoses and services, Table 6 is not expected to reflect the full range of diagnoses and services rendered by a grantee. The selected conditions seen and services provided represent those that are prevalent among BPHC patients or a sub-group of patients or are generally regarded as sentinel indicators of access to primary care. Diagnoses reported on this table are those made by a medical, dental or behavioral health provider only . Thus, if a case manager sees a diabetic patient, the encounter is not to be reported on Table 6.

The table is included in both the Universal Report and Grant Reports.

• The Universal Report reports on encounters in the indicated diagnostic or service categories and a count of all individuals who had at least one encounter in the indicated diagnostic or service category within the scope of any and all BPHC - supported projects included in the UDS.
• The Grant Report reports only those encounters provided and those individuals served within the scope of the program being reported on.

Selected Diagnoses – Lines 1 through 20 present the name and applicable ICD-9CM codes for the diagnosis or diagnostic range/group. Wherever possible, diagnoses have been grouped into code ranges. Where a range of ICD-9CM codes is shown, grantees should report on all encounters where the primary diagnostic code is included in the range/group.

Selected Tests/Screenings/Preventive Services – Lines 21 through 26 present the name and applicable ICD-9CM diagnostic and visit codes and/or CPT procedure codes for selected tests, screenings, and preventive services which are particularly important to the populations served. On several lines both CPT codes and IC9 codes are provided. Grantees should use either the CPT codes or the ICD9 codes for any given line, not both!

Selected Dental Services – Lines 27 through 34 present the name and applicable ADA  procedure codes for selected dental services. Wherever appropriate, services have been grouped into code ranges.  Some codes are included on more than one line.  In these cases the service would be counted on each line.

Instructions for reporting Encounters - Column (a).

LINES 1 – 20: Diagnostic Data.

Encounters by Selected Diagnoses ( Lines 1-20). Report the total number of encounters during the reporting period where the indicated diagnosis is listed on the encounter/billing records as the primary diagnosis only. If an encounter has a primary diagnosis which is one of the many diagnoses not listed on Table 6, it is not reported. Note: while most encounters are not reported on this table, those which are counted, are reported for only the primary diagnosis on lines 1 through 20. All visits are entered into clinic practice management / billing systems, with one diagnosis listed as primary and successive diagnoses listed as secondary, tertiary, etc. Any single encounter may be counted a maximum of one time on lines 1 – 20 regardless of the number of diagnoses listed for the visit.

LINES 21 – 34: Service Data.

Encounters by Selected Tests/Screenings/Preventive and Dental Services ( Lines 21-34). Report the total number of encounters 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) codes or procedure ( ADA or CPT-4) codes. During one encounter more than one test, screening or preventive service may be provided, in which case, each would be counted.

• One encounter may involve more than one of the identified services in which case each should be reported. For example, if during an encounter both a Pap test and an HIV test were provided then an encounter would be reported on both lines 21 and 23.
• If a patient receives multiple immunizations at one visit, only one encounter should be reported.
• Services may be 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 line 21, HIV test.
• If a patient had more than one tooth filled, only one encounter for restorative services should be reported, not one per tooth.

Instructions for reporting Patients - Column (b)

LINES 1 – 20: Diagnostic Data.

Patients by Diagnosis – For Column B report each individual who had one or more encounter during the year where the primary diagnosis was the indicated diagnosis. A patient is counted once and only once regardless of the number of encounters made for that specific diagnosis. Any patient may have encounters with different primary diagnoses, for example, one for hypertension and one for diabetes, on different days. In this case, the patient would be reported once for each primary diagnosis used during the year. For example, a patient with one or more encounters for hypertension is counted once as a patient regardless of how many times they were seen.

LINES 21 – 26: Services Data.

Patients by Selected Diagnostic Tests/Screenings/Preventive Services -- Report patients who have had at least one encounter during the reporting period for the selected diagnostic tests, screenings, and/or preventive services listed on Lines 21-26. If a patient had a Pap test and contraceptive management during the same encounter, 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, they are counted once and only once on that line in Column B. For example, an infant who has multiple well child visits in the year has each visit reported in column A, but is counted only once in column B.

LINES 27 – 34: Dental Services Data.

Patients by Selected Dental Services -- Report patients who have had at least one encounter during the reporting period for the selected dental services listed on Lines 27-34. If a patient had two teeth repaired and sealants applied during one encounter, this patient would be counted once (only) on both Lines 30 and 32 in Column B. Note that some ADA codes are listed twice. For example, the code for “fluoride treatment and prophylaxis” is listed once under fluoride treatments and once under prophylaxis. In these cases the service would be counted on each line.

Questions and Answers for Table 6A

•  Are there any changes to the table this year?

Yes. The Table has been designated as Table 6A. It was designated as “Table 6” in previous years.

•  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 encounters with medical, dental and behavioral health providers on Table 6.

•  The instructions call for diagnoses or services at encounters. If we provide the service, but it is not counted as an encounter (such as immunizations given at a health fair) should it be reported on this table?

If the service is provided as a result of a prescription or plan from an earlier visit it is counted. For example, if a provider asked a woman to come back in four months for a Pap test, it would be counted. But if the service is a self-referral where no clinical visit is necessary or provided (such as a senior citizen coming in for a flu shot,) it is not counted.

•  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 6 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.

•  The instructions specifically say that the source of information for Table 6 is “billing systems.” There are some services for which I do not pay and there are no encounters in my system. What do I do?

While grantees are only required to report data derived from billing systems, the reported data will understate services in the circumstances described. In order to more accurately reflect your level of service, grantees are encouraged to use other sources of information (e.g., referral or tracking logs), although there is no requirement to do so. The following provides examples of these sources.

• Early entry into prenatal care: If women enter care in their first trimester then the probability of adverse birth outcome will be reduced.
• Childhood immunizations: 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
• Pap tests: If women receive Pap tests as recommended then they can be treated earlier and will be less likely to suffer adverse outcomes from HPV and cervical cancer

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 indicators and that individual health centers may be using others in addition to these.

 The table is included only in the Universal Report.

DEMOGRAPHIC CHARACTERISTICS OF PRENATAL CARE PATIENTS, SECTIONS A AND B

Only grantees that provide or assume primary responsibility for some or all of a patient’s prenatal care services, whether or not the grantee does the delivery" are required to complete Sections A and B.

Section A: Age of Prenatal Care Patients (Lines 1-6)

Report the total number of patients who received prenatal care services at any time during the reporting period by age group. Be sure to include all women receiving any prenatal care during the reporting year regardless of when that care was initiated, including women who began prenatal care during the previous reporting period and continued into this reporting period and women who began their care in this reporting period but will not / did not deliver until the next year. Total prenatal patients include patients who began care with another provider, patients who were “risked out” or transferred to another provider at some point during their prenatal care and patients who were delivered by another provider. To determine the appropriate age group, use the woman's age on June 30 of the reporting period.

Section B: Trimester of enty into prenatal care – Lines 7 through 9.

All patients who received prenatal care including but not limited to the delivery of a child [2] during the reporting period, are reported on lines 7– 9. The trimester (line) is determined by the trimester of their pregnancy that they were in when they began prenatal care either at one of the grantee's service delivery locations or with another provider. A woman who begins her prenatal care with the grantee is reported in Column A. A woman who begins her prenatal care at another provider and then transfers to the grantee, 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 the obstetrical care giver, not when she registers for care at the center or has lab tests 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 is in treatment for two separate perinatal courses of care in the same year (e.g., a delivery in February and a new pregnancy in November) she is to be counted twice.

·         First Trimester – Includes women who received prenatal care during the reporting period and whose first visit occurred when she was estimated to be anytime less than 13 weeks after conception. If the woman began prenatal care during the first trimester at the grantee’s service delivery location, she is reported on Line 7 Column A; if she received prenatal care from another provider before coming to the grantee’s service delivery location, she is reported on Line 7 Column B, regardless of when she begins care with grantee.

·         Second Trimester – Includes women who received prenatal care during the reporting period and whose first visit occurred when she was estimated to be between the 13th and through the 26th week after conception. If the woman began prenatal care during the second trimester at the grantee’s service delivery location, she is reported on Line 8 Column A; if she received prenatal care from another provider before coming to the grantee’s service delivery location, she is reported in Column B -- Line 8, regardless of when she begins care with grantee.

·         Third Trimester – Includes women who received prenatal care during the reporting period and whose first visit occurred when she was estimated to be 27 weeks or more after conception. If the woman began prenatal care during the third trimester at the grantee’s service delivery location, she is reported on Line 9 Column A; if she received prenatal care from another provider before coming to the grantee’s service delivery location, she is reported on Line 9 Column B -- Line 9, regardless of when she begins care with grantee.

The sum of the numbers in the six cells of lines 7 through 9 represents the total number of women who received perinatal care from the grantee during the calendar year. All women must be reported here, regardless of when the entered treatment (this year or last year) or when they deliver (this year or next year.)

In these sections, grantees will report on the findings of their reviews of services provided to targeted populations of current medical users (i.e., medical patients who had a medical encounter at least once during the reporting period):

SECTION C: CHILDHOOD IMMUNIZATION (Line 10)
Children with at least one medical encounter during the reporting period, who had their second birthday during the reporting period, and who were first seen prior to their second birthday. For the purposes of this year's reporting this includes children whose date of birth is between January 1, 2006 and December 31, 2006.

SECTION D: PAP TESTS (Line 11)
Women aged 21 through 64 with at least one medical encounter during the reporting period, who were first seen by the clinic at some point prior to their 65th birthday. For the purposes of this year's reporting this includes women whose date of birth is between January 1, 1944 and December 31, 1987.

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 permit the recovery of all records for all patients which fit the sampling profile.
For each of the two populations being surveyed, very rigid and 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. (Special care must be taken since mistakes in this area are quite likely to portray a much lower quality of care than is actually the case.)

Column Instructions:

Column a: Number of Patients in the “Universe”

Enter the total number of health center patients who fit the criteria as defined below. Note that this will include patients who have not received the specific service being measured in particular. Because these populations are initially defined in terms of age (and gender) comparisons to the numbers on Table 3A will be made.

Column a will reflect the total number of patients meeting the criteria in the agency’s total patient population.

Column b: Number of Charts Sampled or EHR total.

Enter the total number of health center patients for whom data have been reviewed. If no EHR is present, this will be all patients who fit the criteria or a scientifically drawn sample of 70 patients, whichever is less.. 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 every patient who meets the criteria described below for inclusion in the universe.

·         Every item in the criteria is regularly recorded for all patients

·         The EHR has been in place long enough to be able to find the data required in prior year’s activities. This means a minimum of two years (immunizations) or three years (Pap tests and lead screening) of full operation for the EHR before it can be used in lieu of chart audits.

If the EHR is to be used in lieu of the chart audit, the number in column B will be equal to the number in column A.

Column c: Number of Charts / Records in Compliance

Enter the total number of records which meet the requirement for compliance as discussed below.

CHILDHOOD IMMUNIZATIONS (Line 10):
PERFORMANCE MEASURE: Percentage of children with 2^nd birthday during the measurement year who are fully immunized.

• Numerator: Number of children among those included in the denominator who are fully immunized on or before their 2nd 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: 4 DTP/DTaP, 3 IPV, 1 MMR, 3 Hib, 3 HepB, 1VZV (Varicella) and 4 Pneumoccocal conjugate prior to or on their 2nd birthday.
  
  
• Denominator: Number of all children with at least one medical encounter during the reporting period, who had their 2nd birthday during the reporting period, who did not have a contraindication for a specific vaccine. For measurement year 2008, this includes children with date of birth on or after January 1, 2006 and on or before December 31, 2006).

TOTAL NUMBER OF PATIENTS WITH 2ND BIRTHDAY DURING MEASUREMENT YEAR, COLUMN (a)

Enter number of children who:

• Were born between January 1, 2006 and December 31, 2006, 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 who were never seen for well child care and
• Were seen for the first time prior to their second birthday. (This could have been in 2006 or 2007.)

Include all children meeting this criterion regardless of whether or not they came to clinic specifically for vaccinations or well child care.

Children who had a contraindication for a specific vaccine should be excluded from the universe. In excluding contraindicated children, this may only be done for those children where the administrative data does not indicate that the contraindicated immunization was rendered. The exclusion must have occurred by the patient’s 2^nd birthday. Contraindications should be looked for as far back as possible in the patient’s history. The following may be used to identify allowable exclusions:

o        Any particular vaccine: Contraindication: Anaphylactic reaction to the vaccine or its components ICD-9: 999.4.

o        DTaP: Contraindication: Encephalopathy ICD-9: 323.5 (must include E948.4 or E948.5 or E948.6 to identify the vaccine).

o        VZV and MMR: Contraindications:

§         Immunodeficiency, including genetic (congenital) immunodeficiency syndromes ICD-9: 279.

§         HIV-infected or household contact with HIV infection ICD-9: Infection V08, symptomatic 042.

§         Cancer of lymphoreticular or histiocytic tissue ICD-9: 200-202.

§         Multiple myeloma ICD-9: 203. Leukemia ICD-9: 204-208.

§         Anaphylactic reaction to neomycin.

o        IPV: Contraindication: Anaphylactic reaction to streptomycin, polymyxin B or neomycin.

o        HiB: Contraindication: None.

o        Hepatitis B: Contraindication: Anaphylactic reaction to common baker’s yeast.

o        Pneumococcal conjugate: Contraindication: None.

NUMBER OF CHARTS SAMPLED OR EHR TOTAL, COLUMN (b)

Enter number of charts sampled or, if an EHR is used, copy the number from column a. The number of charts to be sampled equals all patients who fit the criteria or a scientifically drawn sample of 70 patients from all patients who fit the criteria, whichever is less.

NUMBER OF PATIENTS IMMUNIZED, COLUMN (c)

Enter 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 Pneumoccocal conjugate prior to or on their 2nd birthday. Count any of the following: 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: An initial DTaP vaccination followed by at least three DTaP, DT or individual diphtheria and tetanus shots, on or before the child’s second birthday. Any vaccination administered prior to 42 days after birth cannot be counted. In states where the law allows an exception to a child who receives a pertussis vaccination, the child is compliant if he or she has four diphtheria and four tetanus vaccinations.

IPV: At least three polio vaccinations (IPV) with different dates of service on or before the child’s second 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 on or before the child’s second birthday.

HiB: Three H influenza type B (HiB) vaccination, with different dates of service on or before the child’s second birthday. HiB administered prior to 42 days after birth cannot be counted. Note: because use of the one particular type of HiB vaccine requires only three doses, the measure requires meeting the minimum possible standard of three doses, rather than the recommended four doses, though the intent is to ensure complete HiB vaccination.

Hepatitis B: Three hepatitis B vaccinations, with different dates of service on or before the child’s second 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 on or before the child’s second birthday.

Pneumococcal conjugate: At least four pneumococcal conjugate vaccinations on or before the child’s second birthday.

Combination 2 (DtaP, IPV, MMR, HiB, hepatitis B, VZV): Children who received four DTaP/DT vaccinations; three IPV vaccinations; one MMR vaccination; three HiB vaccinations; three hepatitis B; and one VZV vaccination.

Combination 3 (DtaP, IPV, MMR, HiB, hepatitis B, VZV, pneumococcal conjugate): Children who received all of the antigens listed in combination 2 and four pneumococcal conjugate vaccination.

The following ICD-9 and/or CPT codes are evidence of compliance

DTaP: CPT (90698, 90700, 90701, 90720, 90721, 90723; ICD-9 (99.39)

Diphtheria and tetanus: CPT (90702)

Diphtheria: CPT (90719); ICD-9(V02.4*, 032*, 99.36)

Tetanus: CPT (90703); ICD-9 (037*, 99.38)

Pertussis: ICD-9 (033*, 99.37)

IPV: CPT (90698, 90713, 90723); ICD-9 (V12.02*, 045*, 99.41)

MMR: CPT (90707, 90708); ICD-9 (055*, 99.45)

Measles: CPT (90705, 90708); ICD-9 (055*, 99.45)

Mumps: CPT (90704, 90709); ICD-9 (072*, 99.46)

Rubella: CPT (90706, 90708, 90709); ICD-9 (056*, 99.47)

HiB: CPT (90645, 90646, 90647, 90648, 90698, 90720, 90721, 90748); ICD-9 (041.5*, 038.41*, 320.0*, 482.2*)

Hepatitis B*: CPT(90723, 90740, 90744, 90747, 90748); ICD-9 (V02.61*, 070.2*, 070.3*)

VZV: CPT (90710, 90716); ICD-9 (052*, 053*)

Pneumococcal conjugate: CPT (90669)

* Indicates evidence of disease. A patient who has evidence of the disease during the numerator event time is compliant for the antigen.

For immunization information obtained from the medical record, count patients where there is evidence that the antigen was rendered from a note indicating the name of the specific antigen and the date of the immunization, or a certificate of immunization prepared by an authorized health care provider or agency including the specific dates and types of immunizations administered.

For documented history of illness or a seropositive test result, find a note indicating the date of the event. The event must have occurred by the patient’s second birthday.

Notes in the medical record indicating that the patient received the immunization “at delivery” or “in the hospital” may be counted toward the numerator. This applies only to immunizations 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.  

Also, good faith efforts to get a child immunized which fail remain “non-compliant” including:

• Parental failure to bring in the patient
• Parents who refuse for religious reasons
• Parents who refuse because of beliefs about vaccines

PAP TESTS (Line 11):

PERFORMANCE MEASURE. Percentage of women 21-64 years of age who received one or more Pap tests during the measurement year or during the two years prior to the measurement year.

• Numerator: Number of female patients 21-64 years of age receiving one or more Pap tests during the measurement year or during the two years prior to the measurement year among those women included in the denominator.
• Denominator: Number of all female patients age 21-64 years of age during the measurement year who had at least one medical encounter during the reporting year. For measurement year 2008, this includes patients with a date of birth between January 1, 1944 and December 31, 1987.

TOTAL NUMBER OF FEMALE PATIENTS 21-64 YEARS OF AGE, COLUMN (a)

Enter the number of all female patients who:
• Were born between January 1, 1944 and December 31, 1987 and
• Were first seen in the clinic prior to their 65th birthday and
• Had at least one medical encounter during 2008.

Exclude 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, 56308, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290-58294, 58550, 58551, 58552-58554, 58951, 58953-58954, 58956, 59135) and ICD-9-CM (68.4-68.8, 618.5)

NUMBER OF CHARTS SAMPLED OR EHR TOTAL, COLUMN (b)

Enter number of charts sampled or, if an EHR is used, copy the number from column a. The number of charts to be sampled equals all patients who fit the criteria or a scientifically drawn sample of 70 patients from all patients who fit the criteria, whichever is less.

NUMBER OF PATIENTS TESTED, COLUMN (c)

Number of female patients included in the sample who received one or more Pap tests in a three year period from 2006 to 2008. Documentation in the medical record must include a note indicating the date the test was performed and the result of the finding. A female patient had a Pap test if a submitted claim/encounter contains any one of the following codes or if a copy of a lab test performed by another provider is in the chart or if a note documents the name, date, and results from a test performed by another provider: CPT (88141-88145, 88148, 88150, 88152-88155, 88164-88167, 88174-88175) ICD-9-CM (91.46)

Questions and Answers for Table 6B

1. Are there any changes to the table this year?

Section A and B are not new data elements, they are from the old Table 7 Lines 3-8 and Lines16-18. However, Sections C and are new.

2. A child came in only once in 2008 for an injury and never returned for well child care. If her record is selected do we have to consider her chart to be out of compliance?

Yes. Once a patient enters a CHC’s system of care the center is considered to be responsible to provide all needed preventive health care and/or document that they have 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 part of our sample for Pap tests? 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. The woman would be considered to be a part of your universe if you saw her for any reason in 2008, and if you do not have a copy of the results of her Pap test, her chart would be considered out of compliance.

4. If we pull a chart 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 chart as being in compliance?

The health center should obtain a copy of her test result to include in the patient's record for future care, However, the chart is still out of compliance for the reporting year (although the record will now be valid for successive years depending on when the test was performed.)

5. If we inform a parent of the importance of immunizations but they refuse to have their child immunized may we count the chart as being in compliance 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?

Parents are encouraged to provide documentation of immunizations that their children receive elsewhere, but this is not required. 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 through other appropriate means. Health Center patients should not be requested to return to the center to provide immunization documentation.

TABLE 6B – QUALITY OF CARE INDICATORS

² Note that this is a minor change from prior years. In prior years patients who delivered in early days of the new year but had had their last prenatal care visit in the prior year were not counted. This new table counts those women as well. Thus, a woman whose last prenatal care visit was December, 2007 who delivered on January, 2008 will be reported on the 2008 table.