Copyright. Last updated: September 6, 2017 MicroMD PM UDS Reporting Guide: Performance Year 2017

Transcription

1 Performance Year 2017

2 Trademarks Because of the nature of the material, numerous hardware and software products are mentioned by their trade names in this publication. All product names referenced herein are trademarks of their respective companies. The marks MICROMD, HENRY SCHEIN, and the HENRY SCHEIN LOGO are registered trademarks of HS TM, LLC, a subsidiary of Henry Schein, Inc. Copyright This document is covered by the terms and conditions of the license agreement and/or the non-discloser agreement and may only be reproduced if allowed by the terms of that agreement or with written consent of Henry Schein, Inc. Last updated: September 6, 2017 MicroMD PM UDS Reporting Guide: Performance Year Henry Schein Medical Systems, Inc. All rights reserved.

3 Table of Contents Preface How This Guide is Organized....i Conventions Used in This Guide....i Cross-References....i Text You Type Using the Keyboard....i Keys You Press and Buttons You Click....i Dialog Box, Application Window Titles, and Field Names....i Warnings, Notes and Tips....ii Chapter 1: Overview of MicroMD PM and UDS Reports Overview Terminology Changes for Reporting Year Changes Related to Table 6b Changes Related to Table Chapter 2: Service Area Report In This Chapter Report Options ZIP Code Data Chapter 3: Patient Profile (Tables 3A, 3B, and 4) In This Chapter Report Options Table 3a Universal Patients by Age and by Sex Table 3B Demographic Characteristics Lines 1 through 8: Patients by Race Line 12: Patients by Language Lines 13 through 19: Patients by Sexual Orientation Lines 20 through 26: Patients by Gender Identity Table 4 Selected Patient Characteristics Lines 1 through 6: Income as Percent of Poverty Level Lines 7 through 12: Principal Third-Party Medical Insurance Source Lines 13a through 13c: Managed Care Utilization Lines 14 through 26: Characteristics Special Populations Chapter 4: Staffing and Utilization (Table 5) In This Chapter Prerequisites for Information in the Report Report Options Columns on Table Column A: FTEs Column B: Clinic Visits Column C: Patients MicroMD PM UDS Reporting Guide: Performance Year 2017 TOC.1

4 Table of Contents Chapter 5: Selected Diagnosis and Services Rendered (Table 6a) In This Chapter Report Options Lines 1 through 20d: Diagnostic Category Lines 21 through 34: Service Category Chapter 6: Quality of Care Indicators (Table 6b) In This Chapter Report Options Section A (Lines 1-6): Age Categories for Prenatal Care Patients: Demographic Characteristics of Prenatal Care Patients Section B (Lines 7-9): Early Entry into Prenatal Care Overview of Sections C M (Lines 10 21) Clinical Data for a Specific Patient Columns in Sections C through M of Table 6B Section C (Line 10): Childhood Immunization Status (CMS117v5) Section D (Line 11): Cervical Cancer Screening (CMS124v5) Section E (Line 12): Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (CMS155v5) Section F (Line 13): Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up (CMS69v5) Section G (Line 14a): Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (CMS138v5) Section H (Line 16): Use of Appropriate Medications for Asthma (CMS126v5) Section I (Line 17): Coronary Artery Disease (CAD): Lipid Therapy Line 17, Column A: Total Patients Aged 18 and Older with CAD Diagnosis Line 17, Column B: Number Charts Sampled or EHR Total Line 17, Column C: Number of Patients Prescribed a Lipid Lowering Therapy Exclusions Section J (Line 18): Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic (CMS164v5) Section K (Line 19): Colorectal Cancer Screening (CMS130v5) Section L (Line 20): HIV Linkage to Care Line 20, Column A: Total Patients First Diagnosed with HIV Line 20, Column B: Charts Sampled or EHR Total Line 20, Column C: Number of Patients Seen Within 90 Days of First Diagnosis of HIV Exclusions Section M (Line 21): Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan (CMS2v6) Chapter 7: Health Outcomes and Disparities (Table 7) In This Chapter Report Options Overview Section A: Deliveries and Birth Weight Line 0: HIV Positive Pregnant Women Line 2: Deliveries Performed by Health Center Provider Remaining Lines of Section A Section B: Controlling High Blood Pressure (CMS165v5) Section C: Diabetes: Hemoglobin A1c Poor Control (CMS122v5) TOC.2 MicroMD PM UDS Reporting Guide: Performance Year 2017

5 Table of Contents Chapter 8: Financial (Table 9) In This Chapter Report Options Overview Line 1 through Line Line Appendix A: Service Area Table Appendix B: Tables 3a, 3b, and 4 Appendix C: Table 5 Appendix D: Table 6a Appendix E: Table 6b Appendix F: Table 7 Appendix G: Table 9 MicroMD PM UDS Reporting Guide: Performance Year 2017 TOC.3

6 Table of Contents *** THIS PAGE INTENTIONALLY LEFT BLANK FOR DOUBLE-SIDED PRINTING. *** TOC.4 MicroMD PM UDS Reporting Guide: Performance Year 2017

7 Preface From all of us here at Henry Schein Medical Systems, Inc., thank you for selecting MicroMD. This supplemental guide is a quick reference to the UDS reporting tables supported by MicroMD. How This Guide is Organized This guide was organized according to the UDS tables and the sections/lines within each table. Each section explains how MicroMD determines the values of the various UDS reporting tables. For in-depth information about MicroMD PM or MicroMD EMR, please refer to that software s user s reference manual. Conventions Used in This Guide Before using this guide, it is important to understand the typographical conventions used to identify and describe information. Cross-References Cross-references to chapters, sections, page numbers, headings, etc. are shown in an italic typeface. e.g., Refer to Conventions Used in This Guide page i. Text You Type Using the Keyboard Text that you type using the keyboard is shown in a Courier typeface. e.g., Type Anthony Smith in the Name field. Keys You Press and Buttons You Click Keys that you press on the keyboard and buttons/icons that you click with the mouse are shown in a bold sans-serif typeface. e.g., Press Enter. e.g., Click OK to continue. Dialog Box, Application Window Titles, and Field Names The titles of dialog boxes and application windows are shown in italics. Field names and selections made from drop-down menus, etc. are also shown in italics. e.g., The Print Preview dialog box appears. e.g., Select Commercial Insurance from the drop-down list. MicroMD PM UDS Reporting Guide: Performance Year 2017 i

8 Preface Conventions Used in This Guide Warnings, Notes and Tips Warnings, notes and tips appear throughout the guide. They provide additional information important for you to know about a topic. Warning Table A warning alerts you to a severe situation, a potential for data loss, or other critical information about the actions discussed in the instructions. Note Table A note highlights some important information you need to know to use the features of the system correctly or to get the results you expect. Tip Table This type of tip highlights helpful information you may not know about the system or feature. This type of tip contains a reference to some related information or a related feature on another page or in another section of the manualguide. ii MicroMD PM UDS Reporting Guide: Performance Year 2017

9 Overview of MicroMD PM and UDS Reports Overview The MicroMD PM UDS Reporting Guide: Performance Year 2017 provides you with information on what you can do in MicroMD to meet the requirements of each UDS reporting table. For detailed instructions on using either MicroMD PM or MicroMD EMR, please refer to the appropriate user s reference manual. We have organized this guide into chapters based on the UDS tables, and you can find screenshots of the tables in the appendix for your reference. Along with the locations in MicroMD where you can enter data to meet the requirements, we have also included the list of codes accepted for the various requirements. Terminology For the purposes of this document, you need to understand what we mean when we refer to a qualifying visit. MicroMD deals with charge lines and sequences. When we refer to a qualifying visit, we refer to a sequence that contains a charge line for a procedure code where the Service Category is marked as an Encounter category. Other requirements for the selected report do not necessarily need to occur within that same sequence as long as the Service Dates on the sequences are the same. For example, you have a Service Category called OFFICE VISITS (Figure 1.1). You placed a check mark in the Encounter checkbox for that category. Figure 1.1 Marking a Category as a Visit Category When you set up your procedure codes in the MicroMD CHC module, you associated each visit procedure code with the OFFICE VISIT Service Category (Figure 1.2). Figure 1.2 Associate a Procedure with a Service Category MicroMD PM UDS Reporting Guide: Performance Year

10 Chapter 1. Overview of MicroMD PM and UDS Reports Changes for Reporting Year 2017 Changes for Reporting Year 2017 The following updates were implemented for the UDS reporting tables in MicroMD PM, aside from any minor cosmetic changes like table headings: Changes Related to Table 6b The following updates were made to the Quality of Care Indicators (Table 6b): Section C, Line 10: Childhood Immunization Status has been revised to align with CMS117v5. Section D, Line 11: Cervical Cancer Screening has been revised to align with CMS124v5. Section E, Line 12: Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents has been revised to align with CMS155v5. Section F, Line 13: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow- Up has been revised to align with CMS69v5. Section G, Line 14a: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention has been revised to align with CMS138v5. Section H, Line 16: Use of Appropriate Medications for Asthma has been revised to align with CMS126v5. Section J (Line 18): Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic has been revised to align with CMS164v5. Section K, Line 19: Colorectal Cancer Screening has been revised to align with CMS130v5. Section M, Line 21: Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan has been revised to align with CMS2v6. Changes Related to Table 7 The following updates were made to Health Outcomes and Disparities (Table 7): Section B: Controlling High Blood Pressure has been revised to align with CMS165v5. Section C: Diabetes: Hemoglobin A1c Poor Control has been revised to align withcms122v5. In addition, for use with Table 7, those practices with MicroMD EMR will see the patient s most recent diabetic and hypertension data displayed in the Clinical section. When a user clicks the Clinical Quality Measure Data button, they can see whether the patient meets the measure. This allows users to refresh the data from the EMR using either the Refresh from EMR button or the Refresh Clinical Data utility (under Aux > MicroMD CHC > Utilities). (See the main MicroMD PM User s Reference Manual for more details on refreshing data.) 1.2 MicroMD PM UDS Reporting Guide: Performance Year 2017

11 Service Area Report The Service Area report allows the health center to report the number of patients (and their primary insurance plans) by ZIP code. This information will enable Bureau of Primary Health Care (BPHC) to better identify areas served by health centers. You can find the report under Aux > MicroMD CHC > UDS Reporting Tables > Service Area from the main menu. Table 2.1 explains the fields in more detail. In this chapter, we cover: Report Options (page 2.1) ZIP Code Data (page 2.2) In This Chapter Report Options To generate the report, you need to establish the report s parameters. Each of the patients included in the report must meet the criteria you set on the report options window. Table 2.1 Field Report Options Available for Service Area Description Date of Service Location Diagnosis Procedure Report Type Select the service date range for which you want to generate a report. The default date is January 1 to December 31 of the previous year. You can change this as needed. From the Location drop-down, select the location(s) for which you want the report generated. MicroMD PM includes only those patients with sequences posted against the selected Location during the date range you specify in the Date of Service fields. If you want to generate a report for those patients with only certain diagnosis code(s), select the appropriate code(s) from the Diagnosis drop-down list. You can limit the report even more by selecting a diagnosis/procedure code combination if needed. If you want to generate a report for those patients with only certain procedure code(s), select the appropriate code(s) from the Procedure drop-down list. You can limit the report even more by selecting a diagnosis/procedure code combination if needed. In the Report Type section, identify if you want the system to generate a universal report or one based on 330g, 330h or 330i grant information. MicroMD PM UDS Reporting Guide: Performance Year

12 Chapter 2. Service Area Report ZIP Code Data ZIP Code Data For every patient that MicroMD PM includes in the ZIP Code report, there must be at least one sequence posted to the patient s account with a Service Date that falls within the date range you enter in the Date of Service fields on the report options window. In addition, MicroMD PM looks at the active primary plan for the plan set listed in the Primary Medical Plan Set drop-down (on the Patient Profile Detail tab of the Patient Detail window). Figure 2.1 Primary Medical Plan Set on the Patient Detail Window For those ZIP codes with 10 or fewer patients that meet the criteria of the report, MicroMD PM includes those patients in the Other Zip Codes line. The total number of patients in the Service Area report should match the totals on Table 3a (page 3.2). 2.2 MicroMD PM UDS Reporting Guide: Performance Year 2017

13 Patient Profile (Tables 3A, 3B, and 4) The Patient Profile tables allow you to report necessary user demographic data along with socioeconomic information required in the Universal Report and the Grant Reports for your practice. You can find the report under Aux > MicroMD CHC > UDS Reporting Tables > Patient Profile - Table 3A, 3B, 4 from the main menu. If you want to see the list of patients included in the report numbers, simply click the Show Details icon ( ) in the Task Pane once you generate the report. In This Chapter In this chapter, we cover: Report Options (page 3.1) Table 3a Universal Patients by Age and By Sex Assigned at Birth (page 3.2) Table 3b Demographic Characteristics (page 3.3) Table 4 Selected Patient Characteristics (page 3.5) Report Options For the Tables 3a, 3b, and 4 (Patient Profile) report, you need to set your report options. These allow you to specify the date range, practice location, provider and more for the report you need to submit. Table 3.1 explains these fields in detail. Table 3.1 Field Report Options Available for UDS Tables 3a and 3b, 4 (Patient Profile) Description Date of Service Location Diagnosis Procedure Select the service date range for which you want to generate a report. The default date is January 1 to December 31 of the previous year. You can change this as needed. From the Location drop-down, select the location(s) for which you want the report generated. MicroMD PM includes only those patients with sequences posted against the selected Location during the date range you specify in the Date of Service fields. If you want to generate a report for those patients with only certain diagnosis code(s), select the appropriate code(s) from the Diagnosis drop-down list. You can limit the report even more by selecting a diagnosis/procedure code combination if needed. If you want to generate a report for those patients with only certain procedure code(s), select the appropriate code(s) from the Procedure drop-down list. You can limit the report even more by selecting a diagnosis/procedure code combination if needed. MicroMD PM UDS Reporting Guide: Performance Year

14 Chapter 3. Patient Profile (Tables 3A, 3B, and 4) Table 3a Universal Patients by Age and by Sex Table 3.1 Field Age computed as of Compute percent of poverty based on Each additional family member at Report Type Show Details Report Options Available for UDS Tables 3a and 3b, 4 (Patient Profile) (continued) Description Select the effective date for the calculation of the patients ages in the report. The field defaults to June 30 of the previous year. Edit the Compute percent of poverty based on field if necessary. The default value pulls from the Base Annual Poverty Level field on the Sliding Fee Schedule Setup tab (under Aux > MicroMD CHC > Setup > Practice). The system uses the row set to ALL in the Plan Sets column. Edit the Each additional family member at field if necessary. The default value pulls from the Base Annual Additional Member field on the Sliding Fee Schedule Setup tab (under Aux > MicroMD CHC > Setup > Practice). The system uses the row set to ALL in the Plan Sets column. In the Report Type section, identify if you want the system to generate a universal report or one based on 330g, 330h or 330i grant information. Place a check mark in the Show Details option to display a list of the patients that MicroMD PM used to calculate each of the numbers in the generated report. Once you generate the report, you can also click the Show Details or Suppress Details icon ( ) in the Task Pane to show/hide the patient list, regardless if you choose this option. Table 3a Universal Patients by Age and by Sex For Table 3a, MicroMD PM looks at DOB field and the Sex field on the Patient Detail window. The system looks at this for all of the unique patients in your practice where at least one of the sequences posted to their account has a Service Date that falls within the date range you enter in the Date of Service fields on the report options window. For this report, MicroMD PM counts each patient only once and breaks down the number of patients by male and female. Remember that the patients included in the report must have also met the criteria you set in the report options (page 3.1). 3.2 MicroMD PM UDS Reporting Guide: Performance Year 2017

15 Table 3B Demographic Characteristics Chapter 3. Patient Profile (Tables 3A, 3B, and 4) Figure 3.1 Patient Detail Window The system calculates the patient s age as of the date entered in the Age computed as of report option. The total number of patients displayed in Table 3a must equal the total patients displayed in Table 3b (Line 8) and in Table 4 (Line 6). Table 3B Demographic Characteristics In Table 3b, MicroMD PM looks at the Patient Detail window for all of the unique patients in your practice where at least one of the sequences posted to their account has a Service Date that falls within the date range you enter in the Date of Service fields on the report options window. The system then breaks down the race, language, ethnicity and sexual orientation data of those patients. Remember that the patients included in the report must have also met the criteria you set in the report options (page 3.1). Lines 1 through 8: Patients by Race For Line 1 through Line 8, MicroMD PM counts each patient only once and breaks down the number of patients by race and ethnicity. The system finds this data on the Patient Detail window in the Race and Ethnicity fields (Figure 3.2). Figure 3.2 Race and Ethnicity on the Patient Detail Window Keep in mind that, in MicroMD PM, it is possible to choose multiple ethnicities from the Race and Ethnicity fields: MicroMD PM UDS Reporting Guide: Performance Year

16 Chapter 3. Patient Profile (Tables 3A, 3B, and 4) Table 3B Demographic Characteristics If a staff member enters multiple races in the Race field, the system automatically translates that into Line 6 (More than one Race). If a staff member enters multiple ethnicities in the Ethnicity field and one of those entries is Hispanic, MicroMD PM includes the patient in the Hispanic/Latino column on the report. Otherwise, the patient counts in the Non-Hispanic/Latino column. If a staff member enters Declined to Specify in both the Race and Ethnicity fields, MicroMD PM includes the patient in the Unreported/Refused to Report Ethnicity column. In all others cases, the patient counts in the Non-Hispanic/Latino column. Line 12: Patients by Language In Line 12, MicroMD PM counts each patient only once and displays the number of patients with a check mark in the Limited English Proficiency checkbox (on the Patient Profile Detail tab of the Patient Detail window). Figure 3.3 Limited English Proficiency on the Patient Detail Window Lines 13 through 19: Patients by Sexual Orientation For Line 13 through Line 19, MicroMD PM counts each patient only once and breaks down the number of patients by sexual orientation. The system finds this data on the Patient Detail window in the Sexual Orientation field (Figure 3.4). Figure 3.4 Sexual Orientation on the Patient Detail Window 3.4 MicroMD PM UDS Reporting Guide: Performance Year 2017

17 Table 4 Selected Patient Characteristics Chapter 3. Patient Profile (Tables 3A, 3B, and 4) Lines 20 through 26: Patients by Gender Identity For Line 20 through Line 26, MicroMD PM counts each patient only once and breaks down the number of patients by the gender with which they identify. The system finds this data on the Patient Detail window in the Gender Identity field (Figure 3.5). Figure 3.5 Gender Identity on the Patient Detail Window Table 4 Selected Patient Characteristics Table 4 displays data related to your patients financial characteristics, as well as details about special populations. Remember that the patients included in the report must have also met the criteria you set in the report options (page 3.1). Lines 1 through 6: Income as Percent of Poverty Level Line 1 through Line 6 in Table 4 pull the data from the Family Size and Family Income fields (on the Patient Profile Detail tab of the Patient Detail window) for each patient and calculates the number of patients for each line using the dollar amount you enter in the Compute percent of poverty based on report option. Figure 3.6 Family Size and Family Income on the Patient Detail Window MicroMD PM UDS Reporting Guide: Performance Year

18 Chapter 3. Patient Profile (Tables 3A, 3B, and 4) Table 4 Selected Patient Characteristics Lines 7 through 12: Principal Third-Party Medical Insurance Source For Line 7 through Line 12, MicroMD PM looks at the active primary plan for the plan set listed in the Primary Medical Plan Set drop-down (on the Patient Profile Detail tab of the Patient Detail window). See Figure 2.1 on page 2.2. For Line 9a, if the primary in that plan set is Medicare, the system also looks at the secondary plan in that plan set to see if the patient also has Medicaid and enters the information in Line 9a accordingly. Based on this information, the system looks at the CHC Payor Category field of that plan s Plan Detail window to determine in which line the patient should be counted. You can find the list of Payor Category system codes under Setup > Master Table. Please see the main MicroMD PM User s Reference Manual for more details. The system calculates the patient s age as of the date entered in the Age computed as of report option and includes the patient in the appropriate column. Lines 13a through 13c: Managed Care Utilization MicroMD PM also bases Line 13a through Line 13c on the active primary plan for the plan set listed in the Primary Medical Plan Set drop-down (on the Patient Profile Detail tab of the Patient Detail window). Either one or both of the Effective From and Effective To dates on that primary plan must fall within the Date of Service range entered when generating the report. Figure 3.7 Effective Dates for the Patient s Primary Plan The system compares the plan s effective dates with the Date of Service range entered for the report to determine the number of months the patient was covered. The CHC Payor Category on the plan (Figure 8.1 on page 8.2) must reflect a managed care category. 3.6 MicroMD PM UDS Reporting Guide: Performance Year 2017

19 Table 4 Selected Patient Characteristics Chapter 3. Patient Profile (Tables 3A, 3B, and 4) Lines 14 through 26: Characteristics Special Populations For Line 14 through Line 26, MicroMD PM pulls information from the Social section of the Patient Profile Detail tab (on the Patient Detail window). Figure 3.8 Social Section of the Patient Detail Window MicroMD PM UDS Reporting Guide: Performance Year

20 Chapter 3. Patient Profile (Tables 3A, 3B, and 4) Table 4 Selected Patient Characteristics *** THIS PAGE INTENTIONALLY LEFT BLANK FOR DOUBLE-SIDED PRINTING. *** 3.8 MicroMD PM UDS Reporting Guide: Performance Year 2017

21 Staffing and Utilization (Table 5) This report in MicroMD PM consolidates information on staffing full-time equivalents by position, and visits and patients by provider type and service type. You can find the report under Aux > MicroMD CHC > UDS Reporting Tables > Staffing and Utilization - Table 5 from the main menu. Table 4.1 on page 4.1 explains the options for this report in more detail. In this chapter, we cover: In This Chapter Prerequisites for the information in the report (page 4.1) Report options (page 4.1) Column descriptions (page 4.2) Prerequisites for Information in the Report Before the information displayed in this report can be accurate, you need to ask the following questions: Have we created service categories on the Service Categories tab (under Aux > MicroMD CHC > Setup > Practice)? Have we assigned those service categories to the appropriate procedure codes on the Procedure List window (under Aux > MicroMD CHC > Setup > Procedure) so that those sequences containing those procedures count as encounters/visits? Have we made a selection in the Major Service Category drop-down on the CHC module s Provider Detail window for every provider to be included on the report (under Aux > MicroMD CHC > Setup > Provider)? Have we calculated each provider s full-time equivalency and entered that information on the Full Time Equivalency field on the CHC module s Provider Detail window (for those providers for whom we want to report)? Report Options To generate the Staffing and Utilization Report, you need to establish your reporting criteria. Table 4.1 explains the options in detail. Table 4.1 Report Options Available for Staffing and Utilization - Table 5 Field Description Date of Service Location Select the service date range for which you want to generate a report. The default date is January 1 to December 31 of the previous year. You can change this as needed. From the Location drop-down, select the location(s) for which you want the report generated. MicroMD PM includes only those patients with sequences posted against the selected Location during the date range you specify in the Date of Service fields. MicroMD PM UDS Reporting Guide: Performance Year

22 Chapter 4. Staffing and Utilization (Table 5) Columns on Table 5 Table 4.1 Field Diagnosis Procedure Report Options Available for Staffing and Utilization - Table 5 (continued) Description If you want to generate a report for those patients with only certain diagnosis code(s), select the appropriate code(s) from the Diagnosis drop-down list. You can limit the report even more by selecting a diagnosis/procedure code combination if needed. If you want to generate a report for those patients with only certain procedure code(s), select the appropriate code(s) from the Procedure drop-down list. You can limit the report even more by selecting a diagnosis/procedure code combination if needed. Age computed as of Report Type No Prenatal Care Provided Show Details Show Provider Details Select the effective date for the calculation of the patients ages in the report. The field defaults to June 30 of the previous year. In the Report Type section, identify if you want the system to generate a universal report or one based on 330g, 330h or 330i grant information. This option is currently not in use. To include a detailed list of the patients included in the numbers of the report, place a check mark in the Show Details checkbox. You can only choose either Show Details or Show Provider Details for the report. You cannot choose both. Place a check mark in this checkbox to include totals for each provider as a line item in each category. You can only choose either Show Details or Show Provider Details for the report. You cannot choose both. Columns on Table 5 The information in the columns of Table 5 bases the information displayed on those sequences where the Service Date of the sequence falls within the date range you enter in the Date of Service fields on the report options window. Column A: FTEs MicroMD PM calculates the number of full-time equivalencies based on whether sequences were posted for each provider within the categories listed on the report. If the provider has seen multiple patients during the date range entered in the Date of Service fields on the report options, the system counts the provider only once for the FTEs column. Column B: Clinic Visits The number displayed in the Clinic Visits column reflects the total number of sequences posted for the providers listed in the FTEs column. This includes all patient visits for the provider, even if the patient was seen more than once. There are a few conditions: The sequence must contain a procedure code that has a Service Category associated with it where the Service Category is marked as a visit code. This means there is a check mark in the Encounter column (Figure 4.1) for the Service Category. 4.2 MicroMD PM UDS Reporting Guide: Performance Year 2017

23 Columns on Table 5 Chapter 4. Staffing and Utilization (Table 5) Figure 4.1 Service Category for Encounter/Visit Codes MicroMD PM uses the Service Date on the charge line for the visit procedure code, not the sequence-level Service Date. The system counts one visit per visit code service date, per patient, per provider. The Service Date on the visit code charge line falls within the date range entered in the Date of Service fields on the report options window. Column C: Patients MicroMD PM only displays the total number of unique patients with sequences posted during the date range entered in the Date of Service fields on the report options window for those providers in the Major Service Categories above the total line. MicroMD PM UDS Reporting Guide: Performance Year

24 Chapter 4. Staffing and Utilization (Table 5) Columns on Table 5 *** THIS PAGE INTENTIONALLY LEFT BLANK FOR DOUBLE-SIDED PRINTING. *** 4.4 MicroMD PM UDS Reporting Guide: Performance Year 2017

25 Selected Diagnosis and Services Rendered (Table 6a) Table 6a consolidates posting information and reports on primary diagnoses for medical visits and selected services provided. You can find the report under Aux > MicroMD CHC > UDS Reporting Tables > Selected Diagnosis and Services Rendered - Table 6A from the main menu. Table 5.1 explains the fields in more detail. In this table, you can have a qualifying visit (i.e., a sequence containing a procedure code marked as an encounter code). The diagnosis or procedure required for the Line in Table 6a could be on a separate sequence from that qualifying visit and even be on a sequence with an encounter code. In This Chapter In this chapter, we cover: Report Options (page 5.1) Lines 1 through 20d: Diagnostic Category (page 5.2) Lines 21 through 34: Service Category (page 5.2) Report Options To generate the report, you must first establish your reporting criteria. Only patients who meet the criteria on the report options appear on the report. Table 5.1 explains the options in detail. Table 5.1 Field Report Options Available for Table 6A Description Date of Service Location Age computed as of Report Type Select the service date range for which you want to generate a report. The default date is January 1 to December 31 of the previous year. You can change this as needed. From the Location drop-down, select the location(s) for which you want the report generated. MicroMD PM includes only those patients with sequences posted against the selected Location during the date range you specify in the Date of Service fields. Select the effective date for the calculation of the patients ages in the report. The field defaults to June 30 of the previous year. In the Report Type section, identify if you want the system to generate a universal report or one based on 330g, 330h or 330i grant information. MicroMD PM UDS Reporting Guide: Performance Year

26 Chapter 5. Selected Diagnosis and Services Rendered (Table 6a) Lines 1 through 20d: Diagnostic Category Table 5.1 Field Report Options Available for Table 6A (continued) Description Show Details To include a detailed list of the patients included in the numbers of the report, place a check mark in the Show Details checkbox. You can only choose either Show Details or Show Provider Details for the report. You cannot choose both. Lines 1 through 20d: Diagnostic Category For Line 1 through Line 20d, MicroMD PM counts only those sequences where the service date of the sequence falls within the date range you entered in the Date of Service fields on the report options window. For each line: The Visits with diagnosis Regardless of primacy column reflects only those sequences within that date range that contain the indicated diagnosis code(s) on any transaction line. The Total patients with diagnosis Regardless of primacy column reflects the total unique patients to whom those sequences were posted. If a patient had more than one sequence with the indicated diagnosis code(s), each visit would appear in the Visits with diagnosis Regardless of primacy column, but the patient would appear only once in the Total patients with diagnosis Regardless of primacy column. For Lines 21 through 34, the diagnosis code does not have to appear as the primary diagnosis in order to count in Column A. Lines 21 through 34: Service Category For Line 21 through Line 44, MicroMD PM counts only those sequences where the service date of the sequence falls within the date range you entered in the Date of Service fields on the report options window. For each line: The Number of Visits column reflects only those sequences within that date range that contain the indicated diagnosis and/or procedure code(s). The Number of Patients column reflects the total unique patients to whom those sequences were posted. If a patient had more than one sequence, each visit would appear in the Number of Visits column, but the patient would appear only once in the Number of Patients column. Make sure that you have assigned service categories to your procedures under Aux > MicroMD CHC > Setup > Procedures. Otherwise, the procedure will not be included in the report. For Lines 21 through 34, the diagnosis code does not have to appear as the primary diagnosis in order to count in the Number of Visits column. 5.2 MicroMD PM UDS Reporting Guide: Performance Year 2017

27 Quality of Care Indicators (Table 6b) Table 6: Quality of Care Indicators reports data on certain Clinical Quality Measures (CQMs) consistent with the National Quality Strategy and other national quality initiatives. The quality measures for the UDS report tables align closely to the CQMs outlined by the Centers for Medicaid and Medicare (CMS). Each heading in this chapter identifies the CQM to which the section aligns. For a patient to be included in this UDS report, they must have a qualifying visit within the year you enter in the Dates of Service field on the report options window. Refer to page 1.1 for details on what is a qualifying visit. If the patient does not appear in Table 3a (page 3.2), they will not appear in Table 6b. In this chapter, we cover: Report Options (page 6.2) In This Chapter Section A (Lines 1-6): Age Categories for Prenatal Care Patients: Demographic Characteristics of Prenatal Care Patients (page 6.2) Section B (Lines 7-9): Early Entry into Prenatal Care (page 6.3) Section C (Line 10): Childhood Immunization Status (page 6.6) Section D (Line 11): Cervical Cancer Screening (page 6.6) Section E (Line 12): Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (page 6.7) Section F (Line 13): Preventive Care and Screening: Body Mass Index Screening and Follow-Up (page 6.7) Section G (Line 14a): Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (page 6.8) Section H (Line 16): Use of Appropriate Medications for Asthma (page 6.8) Section I (Line 17): Coronary Artery Disease (CAD): Lipid Therapy (page 6.9) Section J (Line 18): Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic (page 6.11) Section K (Line 19): Colorectal Cancer Screening (page 6.11) Section L (Line 20): HIV Linkage to Care (page 6.12) Section M (Line 21): Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan (page 6.13) MicroMD PM UDS Reporting Guide: Performance Year

28 Chapter 6. Quality of Care Indicators (Table 6b) Report Options Report Options This report in MicroMD PM consolidates information on Quality of Care Indicators. You can find the report under Aux > MicroMD CHC > UDS Reporting Tables > Quality of Care Indicators - Table 6B from the main menu. Table 6.1 explains the fields in more detail. Table 6.1 Field Report Options Available for Quality of Care Indicators - Table 6B Description Date of Service Location Diagnosis Procedure Report Type Select the service date range for which you want to generate a report. The default date is January 1 to December 31 of the previous year. You can change this as needed. From the Location drop-down, select the location(s) for which you want the report generated. MicroMD PM includes only those patients with sequences posted against the selected Location during the date range you specify in the Date of Service fields. If you want to generate a report for those patients with only certain diagnosis code(s), select the appropriate code(s) from the Diagnosis drop-down list. You can limit the report even more by selecting a diagnosis/procedure code combination if needed. If you want to generate a report for those patients with only certain procedure code(s), select the appropriate code(s) from the Procedure drop-down list. You can limit the report even more by selecting a diagnosis/procedure code combination if needed. In the Report Type section, identify if you want the system to generate a universal report or one based on 330g, 330h or 330i grant information. Section A (Lines 1-6): Age Categories for Prenatal Care Patients: Demographic Characteristics of Prenatal Care Patients In this section, you need to report the age of all prenatal care patients you have seen during the reporting year. You identify a prenatal patient with the Prenatal User checkbox on the Patient Profile Detail tab (under Maint > Patient > open the patient s account). Figure 6.1 Prenatal Section of Patient Detail In order for those patients to be counted, the patient must also have a pregnancy listed in the Pregnancy History section of the Patient Profile Detail tab (Figure 6.2) where either the date entered in the First Prenatal Visit field OR the date entered in the Delivery / End Date field is between January 1 and December 31 of the year you enter on the report options window. 6.2 MicroMD PM UDS Reporting Guide: Performance Year 2017

29 Section B (Lines 7-9) Chapter 6. Quality of Care Indicators (Table 6b) Figure 6.2 Pregnancy History Section of Patient Detail The patients must also have had at least one sequence posted to their account where the Service Date on the visit code falls within the year you enter in the Dates of Service field on the report options window. Prenatal information entered in MicroMD PM syncs automatically with the prenatal information in the EMR (and vice versa). Section B (Lines 7-9): Early Entry into Prenatal Care Section B compiles information about when your prenatal care patients began to receive care. You identify a prenatal patient with the Prenatal User checkbox on the Patient Profile Detail tab (under Maint > Patient > open the patient s account). See Figure 6.1 on page 6.2. MicroMD PM pulls the information for Lines 7 9 and separates the numbers based on the Began Prenatal Care in Trimester checkboxes you can find on the Pregnancy Detail window (Figure 6.3). Figure 6.3 Pregnancy Detail Window MicroMD PM UDS Reporting Guide: Performance Year

30 Chapter 6. Quality of Care Indicators (Table 6b) Overview of Sections C M (Lines 10 21) In addition, that pregnancy only counts when either the date entered in the First Prenatal Visit field OR the date entered in the Delivery / End Date field for that pregnancy is between January 1 and December 31 of the year you enter on the Report Options window. Overview of Sections C M (Lines 10 21) The remainder of Table 6B reports on a variety of quality measures consistent with the national quality initiatives. Many of the sections align with Clinical Quality Measures outlined by the Centers for Medicare and Medicaid (CMS) for their incentive programs. In this UDS reporting guide, we refer you to the MicroMD EMR Clinical Quality Measurement Calculations Guide: Performance Year 2017 for details on how the system calculates the numbers in each column. You can find the document on the MicroMD Lounge at Clinical Data for a Specific Patient If you question whether a patient should be included in a line item on the Table 6B report for Lines 10 through 21, MicroMD PM provides a window where you can see whether a specific patient currently meets the conditions to appear for each line of the table. You can find this window on the patient s account under Maint > Patient. Open the patient s account and click the Patient Profile Detail tab. When you click the Clinical Quality Measure Data button, the system displays the Patient - CHC UDS Clinical Data window (Figure 6.4). An overnight process runs each day to update this data based on entries made or changed in MicroMD EMR. Figure 6.4 Patient - CHC UDS Clinical Data Window Enter the reporting year you want to check and click the View button. The system displays a check mark in each of the conditions that the patient meets. If there is no check mark, the patient did not meet the condition. 6.4 MicroMD PM UDS Reporting Guide: Performance Year 2017

31 Overview of Sections C M (Lines 10 21) Chapter 6. Quality of Care Indicators (Table 6b) If you do not have MicroMD PM + EMR, you can edit this window to populate the report accordingly. Otherwise, the data is read-only and displays the information entered from MicroMD EMR. When you highlight a condition, MicroMD PM displays the UDS report table and line number, along with a brief description, at the bottom of the window. (Use the arrow keys on the keyboard to navigate the list quickly.) Click the Refresh from EMR button to rebuild the quality measures data for the patient. You can also rebuild the clinical data for all patients under Aux > MicroMD CHC > Utilities > Refresh Clinical Data. These actions clear out the existing data and refresh the data with the most current information. Columns in Sections C through M of Table 6B The Bureau of Primary Health Care (BPHC) has divided each section into three columns. These columns reflect the numbers used to calculate your compliance with each measure. Most sections align with the Clinical Quality Measures (CQM) outlined by the Centers for Medicare and Medicaid (CMS). Even though the measures are aligned, you should not expect the actual numbers between the PM and the EMR to match. When we refer to the CQM, this is meant to explain how the system gathers patient data from the EMR to then apply the requirements of the UDS reports. Column A (Denominator): This column reflects the number of patients in the universe of the measure. Do not compare the numbers in Column A of Table 6B with numbers calculated for Table 3A. They WILL NOT be equal because the patient populations are different. Column B (becomes the Denominator): Since you are using MicroMD PM and MicroMD EMR (or MicroMD PM alone), Column B will always be the same as Column A. Column C (Numerator): In Column C, the report displays the total number of patients in Column A who meet the measurement standard for the measure. You can calculate the percentage of patient records meeting the measurement standard by dividing Column C by Column B. MicroMD PM UDS Reporting Guide: Performance Year

32 Chapter 6. Quality of Care Indicators (Table 6b) Section C (Line 10) Section C (Line 10): Childhood Immunization Status (CMS117v5) For Line 10, the report displays the numbers needed to calculate the Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. Remember: If you do not use MicroMD EMR, you need to make sure that you make the appropriate selections under the Clinical Quality Measure Data button of each patient s Patient Profile Detail tab. The UDS measure aligns with the Clinical Quality Measure displayed in the heading to this section. Please refer to the MicroMD EMR Clinical Quality Measurement Calculations Guide: Performance Year 2017 for more details. Column A (Total Patients with 2nd Birthday): Use the instructions from the Denominator in the CQM. Column B (Charts Sampled or EHR Total): In MicroMD PM, Column B is the same as Column A. Column C (Number of Patients Immunized): Use the instructions from the Numerator in the CQM. Click here for a searchable list of codes used for this measure. Section D (Line 11): Cervical Cancer Screening (CMS124v5) For Line 11, the report displays the numbers needed to calculate the Percentage of women years of age who were screened for cervical cancer using either of the following criteria: Women age who had cervical cytology performed every 3 years Women age who had cervical cytology/human papilloma virus (HPV) co-testing performed every 5 years. Remember: If you do not use MicroMD EMR, you need to make sure that you make the appropriate selections under the Clinical Quality Measure Data button of each patient s Patient Profile Detail tab. The UDS measure aligns with the Clinical Quality Measure (CQM) displayed in the heading to this section. Please refer to the MicroMD EMR Clinical Quality Measurement Calculations Guide: Performance Year 2017 for more details. Column A (Total Female Patients Years of Age): Use the instructions from the Denominator in the CQM. Column B (Charts Sampled or EHR Total): In MicroMD PM, Column B is the same as Column A. Column C (Number of Patients Tested): Use the instructions from the Numerator in the CQM. Click here for a searchable list of codes used for this measure. 6.6 MicroMD PM UDS Reporting Guide: Performance Year 2017

33 Section E (Line 12) Chapter 6. Quality of Care Indicators (Table 6b) Section E (Line 12): Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (CMS155v5) Line 12 reports on the Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Remember: If you do not use MicroMD EMR, you need to make sure that you make the appropriate selections under the Clinical Quality Measure Data button of each patient s Patient Profile Detail tab. The UDS measure mostly aligns with the Clinical Quality Measure (CQM) displayed in the heading to this section. The only difference between the UDS measure and the CQM referenced above is that the UDS report does not separate the data into different percentages. Please refer to the MicroMD EMR Clinical Quality Measurement Calculations Guide: Performance Year 2017 for more details. Column A (Total Patients Aged 3 17): Use the instructions from Denominator X in the CQM. Column B (Charts Sampled or EHR Total): In MicroMD PM, Column B is the same as Column A. Column C (Number of Patients with Counseling and BMI Documented): Use the instructions for all three Numerator conditions; however, in the UDS report, a patient appears in Column C only if they meet all three numerator conditions in the CQM. Click here for a searchable list of codes used for this measure. Section F (Line 13): Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up (CMS69v5) Line 13 reports on the Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter. Normal Parameters: Age 18 years and older BMI greater than or equal to 18.5 and less than 25 kg/m 2. Remember: If you do not use MicroMD EMR, you need to make sure that you make the appropriate selections under the Clinical Quality Measure Data button of each patient s Patient Profile Detail tab. The UDS measure aligns with the Clinical Quality Measure (CQM) displayed in the heading to this section. Please refer to the MicroMD EMR Clinical Quality Measurement Calculations Guide: Performance Year 2017 for more details. Column A (Total Patients 18 and Over): Use the instructions from the Denominator in the CQM. Column B (Charts Sampled or EHR Total): In MicroMD PM, Column B is the same as Column A. Column C (Number of Patients with BMI Charted and Follow-up Plan Documented as Appropriate): Use the instructions from the Numerator in the CQM. Click here for a searchable list of codes used for this measure. MicroMD PM UDS Reporting Guide: Performance Year

34 Chapter 6. Quality of Care Indicators (Table 6b) Section G (Line 14a) Section G (Line 14a): Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (CMS138v5) Line 14a reports on the Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. Remember: If you do not use MicroMD EMR, you need to make sure that you make the appropriate selections under the Clinical Quality Measure Data button of each patient s Patient Profile Detail tab. The UDS measure aligns with the Clinical Quality Measure (CQM) displayed in the heading to this section. Please refer to the MicroMD EMR Clinical Quality Measurement Calculations Guide: Performance Year 2017 for more details. Column A (Total Patients Aged 18 and Older): Use the instructions from the Denominator in the CQM. Column B (Charts Sampled or EHR Total): In MicroMD PM, Column B is the same as Column A. Column C (Number of Patients Assessed for Tobacco Use and Provided Intervention if a Tobacco User): Use the instructions from the Numerator in the CQM. Click here for a searchable list of codes used for this measure. Section H (Line 16): Use of Appropriate Medications for Asthma (CMS126v5) Line 16 reports on the Percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately ordered medication during the measurement period. Remember: If you do not use MicroMD EMR, you need to make sure that you make the appropriate selections under the Clinical Quality Measure Data button of each patient s Patient Profile Detail tab. The UDS measure mostly aligns with the Clinical Quality Measure (CQM) displayed in the heading to this section. The only difference between the UDS measure and the CQM referenced above is that the UDS report does not separate the data into different percentages. Please refer to the MicroMD EMR Clinical Quality Measurement Calculations Guide: Performance Year 2017 for more details. Column A (Total Patients Aged 5 through 64 with Persistent Asthma): Use the instructions from Denominator A in the CQM. Column B (Charts Sampled or EHR Total): In MicroMD PM, Column B is the same as Column A. Column C (Number of Patients with Acceptable Plan): Use the instructions from the Numerator in the CQM. Click here for a searchable list of codes used for this measure. 6.8 MicroMD PM UDS Reporting Guide: Performance Year 2017

35 Section I (Line 17) Chapter 6. Quality of Care Indicators (Table 6b) Section I (Line 17): Coronary Artery Disease (CAD): Lipid Therapy Line 17 reports on the Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed a lipid-lowering therapy. Remember: If you do not use MicroMD EMR, you need to make sure that you make the appropriate selections under the Clinical Quality Measure Data button of each patient s Patient Profile Detail tab. Click here for a searchable list of codes used for this measure. Line 17, Column A: Total Patients Aged 18 and Older with CAD Diagnosis Column A displays the total number of patients in your practice whose age MicroMD calculates to be greater than or equal to 18 by the end of year you enter in the Dates of Service field on the report options window. In addition, those patients must have an encounter created in MicroMD EMR, as well as at least one sequence posted in MicroMD PM with a visit code, whose Service Date falls within the year you enter in the Dates of Service field on the report options window. The patient must also have at least two encounters/ sequences over the practice s entire history in MicroMD PM with visit codes. (This can include the encounter/ sequence that occurred during the reporting year.) The patient must also have a CAD diagnosis code or a cardiac surgery procedure code in one of the following locations. The date in the Onset field for the diagnosis or the date that the surgery was performed needs to be BEFORE the Service Date on the qualifying encounter/sequence. See the reporting manual provided by the Bureau of Primary Health Care for a list of accepted codes. Coronary artery disease diagnosis (including myocardial infarction) - Medical Information tab > Medical > Problem List - Encounter > Assessment tab Cardiac surgery procedure - Encounter > Plan > Procedure Orders (with Performed status) - Medical Information tab > Orders > Procedure Orders (with Performed status) - Medical Information tab > Histories > Surgical Procedures - Medical Information tab > Histories > Surgical History MicroMD checks the procedure names in the Surgical History. The system includes user-defined procedures only if the user entered the appropriate CPT/HCPCS code. MicroMD PM UDS Reporting Guide: Performance Year

36 Chapter 6. Quality of Care Indicators (Table 6b) Section I (Line 17) Line 17, Column B: Number Charts Sampled or EHR Total In MicroMD PM, Column B for Line 17 will always be identical to Column A. Line 17, Column C: Number of Patients Prescribed a Lipid Lowering Therapy The number in Column C reflects the number of patients within Column B who received at least one prescription for a preferred therapy prior to the end of the year you enter in the Dates of Service field on the report options window. MicroMD checks the following location in the EMR for any of the appropriate medication: Medical Information tab > Medical > Medications See the reporting manual provided by the Bureau of Primary Health Care for a list of accepted medications. Exclusions If the patient is allergic to lipid-lowering medications or has had an adverse reaction to those medications, MicroMD excludes that patient from Columns A and B. MicroMD checks for allergies in the following areas of the patient s chart in the EMR: Medical Information tab > Medical > Allergies Medical Information tab > Medical > Medications (End Date of the medication falls before the end of the year you enter in the Dates of Service field on the report options window and the selection from the Code drop-down is Adverse Reaction.) Figure 6.5 Terminating a Prescription 6.10 MicroMD PM UDS Reporting Guide: Performance Year 2017

37 Section J (Line 18) Chapter 6. Quality of Care Indicators (Table 6b) Section J (Line 18): Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic (CMS164v5) Line 18 reports on the Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period. Remember: If you do not use MicroMD EMR, you need to make sure that you make the appropriate selections under the Clinical Quality Measure Data button of each patient s Patient Profile Detail tab. The UDS measure aligns with the Clinical Quality Measure (CQM) displayed in the heading to this section. Please refer to the MicroMD EMR Clinical Quality Measurement Calculations Guide: Performance Year 2017 for more details. Column A (Total Patients Aged 18 and Older with IVD Diagnosis or AMI, CABG, or PCI Procedure): Use the instructions from the Denominator in the CQM. Column B (Charts Sampled or EHR Total): In MicroMD PM, Column B is the same as Column A. Column C (Number of Patients with Documentation of Aspirin or Other Antithrombotic Therapy): Use the instructions from the Numerator in the CQM. Click here for a searchable list of codes used for this measure. Section K (Line 19): Colorectal Cancer Screening (CMS130v5) Line 19 reports on the Percentage of adults years of age who had appropriate screening for colorectal cancer. Remember: If you do not use MicroMD EMR, you need to make sure that you make the appropriate selections under the Clinical Quality Measure Data button of each patient s Patient Profile Detail tab. The UDS measure aligns with the Clinical Quality Measure (CQM) displayed in the heading to this section. Please refer to the MicroMD EMR Clinical Quality Measurement Calculations Guide: Performance Year 2017 for more details. Column A (Total Patients Aged 50 through 75): Use the instructions from the Denominator in the CQM. Column B (Charts Sampled or EHR Total): In MicroMD PM, Column B is the same as Column A. Column C (Number of Patients with Appropriate Screening for Colorectal Cancer): Use the instructions from the Numerator in the CQM. Click here for a searchable list of codes used for this measure. MicroMD PM UDS Reporting Guide: Performance Year

38 Chapter 6. Quality of Care Indicators (Table 6b) Section L (Line 20) Section L (Line 20): HIV Linkage to Care Line 20 reports on the Percentage of patients newly diagnosed with HIV who were seen for follow-up treatment within 90 days of diagnosis. Remember: If you do not use MicroMD EMR, you need to make sure that you make the appropriate selections under the Clinical Quality Measure Data button of each patient s Patient Profile Detail tab. Click here for a searchable list of codes used for this measure. Line 20, Column A: Total Patients First Diagnosed with HIV For Column A, MicroMD PM displays the number of patients in your practice s database who were first diagnosed with HIV between October 1 of the prior year and September 30 of the reporting year, based on the year you enter in the Dates of Service field on the report options window. There must be no HIV diagnosis entries earlier than October 1 of the prior year. The patient must also have an encounter created in MicroMD EMR, as well as at least one sequence posted in MicroMD PM with a visit code, whose Service Date falls within the year you enter in the Dates of Service field on the report options window or during the previous year (e.g., reporting year 2017 or previous year 2016). You can find the list of encounters on the patient s Summary tab in the EMR or in the list of the patient s sequences in the PM (under Billing > Charges/Payments). MicroMD determines the patient s diagnosis time frame by looking for one of the accepted codes in the following locations and checking the date in the Onset field of that diagnosis. See the reporting manual provided by the Bureau of Primary Health Care for the accepted codes. Medical Information tab > Medical > Problem List (includes Active, Inactive or Resolved) Encounter > Assessment tab Medical Information tab > Histories > Hospitalization History (Diagnoses field) Medical Information tab > Histories > Medical History (Diagnosis field) Medical Information tab > Histories > Surgical Procedures > Medical Details tab (Diagnosis before operation and Diagnosis after operation fields) Medical Information tab > Orders > Laboratory Orders (Diagnoses field) Line 20, Column B: Charts Sampled or EHR Total In MicroMD PM, Column B for Line 20 will always be identical to Column A. Line 20, Column C: Number of Patients Seen Within 90 Days of First Diagnosis of HIV Column C displays the number of patients from Column B who have had an encounter created in the EMR (as well as a sequence in the PM) that contains an appropriate follow-up visit code or an appropriate 6.12 MicroMD PM UDS Reporting Guide: Performance Year 2017

39 Section M (Line 21) Chapter 6. Quality of Care Indicators (Table 6b) procedure code. See the reporting manual provided by the Bureau of Primary Health Care for a list of accepted codes. The Date of Service on the encounter/ visit code must be between one and 90 days after the date in the Onset field of the HIV diagnosis entry in the EMR. Exclusions There are no exclusions for this line item. Section M (Line 21): Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan (CMS2v6) Line 20 reports on the Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen. Remember: If you do not use MicroMD EMR, you need to make sure that you make the appropriate selections under the Clinical Quality Measure Data button of each patient s Patient Profile Detail tab. The UDS measure aligns with the Clinical Quality Measure (CQM) displayed in the heading to this section. Please refer to the MicroMD EMR Clinical Quality Measurement Calculations Guide: Performance Year 2017 for more details. Column A (Total Patients Aged 12 and Older): Use the instructions from the Denominator in the CQM. Column B (Charts Sampled or EHR Total): In MicroMD PM, Column B is the same as Column A. Column C (Number of Patients Screened for Depression and Follow-up Plan Documented as Appropriate): Use the instructions from the Numerator in the CQM. Click here for a searchable list of codes used for this measure. MicroMD PM UDS Reporting Guide: Performance Year

40 Chapter 6. Quality of Care Indicators (Table 6b) Section M (Line 21) *** THIS PAGE INTENTIONALLY LEFT BLANK FOR DOUBLE-SIDED PRINTING. *** 6.14 MicroMD PM UDS Reporting Guide: Performance Year 2017

41 Health Outcomes and Disparities (Table 7) This table reports indicators of overall community health and shows these selected health outcome indicators based on race and ethnicity. You can find the report under Aux > MicroMD CHC > UDS Reporting Tables > Health Outcomes and Disparities - Table 7 from the main menu. Table 7.1 explains the fields in more detail. In this chapter, we cover: Report Options (page 7.1) Overview of the report (page 7.2) In This Chapter Section A: Deliveries and Birth Weight (page 7.2) Section B: Controlling High Blood Pressure (page 7.3) Section C: Diabetes by Race and Hispanic/Latino Ethnicity (page 7.4) Report Options To generate the report, you must first establish your reporting criteria. Only patients who meet the criteria on the report options appear on the report. Table 7.1 explains the options in detail. Table 7.1 Report Options Available for Health Outcomes and Disparities - Table 7 Field Description Date of Service Location Diagnosis Procedure Age computed as of Report Type Select the service date range for which you want to generate a report. The default date is January 1 to December 31 of the previous year. You can change this as needed. From the Location drop-down, select the location(s) for which you want the report generated. MicroMD PM includes only those patients with sequences posted against the selected Location during the date range you specify in the Date of Service fields. If you want to generate a report for those patients with only certain diagnosis code(s), select the appropriate code(s) from the Diagnosis drop-down list. You can limit the report even more by selecting a diagnosis/procedure code combination if needed. If you want to generate a report for those patients with only certain procedure code(s), select the appropriate code(s) from the Procedure drop-down list. You can limit the report even more by selecting a diagnosis/procedure code combination if needed. Select the effective date for the calculation of the patients ages in the report. The field defaults to June 30 of the previous year. In the Report Type section, identify if you want the system to generate a universal report or one based on 330g, 330h or 330i grant information. MicroMD PM UDS Reporting Guide: Performance Year

42 Health Outcomes and Disparities (Table 7) Overview Overview All of the sections in this report display data based on the race and ethnicity of the patients in your practice. For all of the sections on this report, the race and ethnicity of each patient comes from the selections made in the Race and Ethnicity fields on the Patient Detail window for the patient: If a staff member enters multiple races in the Race field, the system automatically translates that into Line 1f (More than one Race). If a staff member enters multiple ethnicities in the Ethnicity field and one of those entries is Hispanic, MicroMD PM includes the patient in the Hispanic/Latino section of the report. If a staff member enters Non-Hispanic or All Others the Ethnicity field, MicroMD PM includes the patient in the Non-Hispanic/Latino section of the report. If a staff member enters Declined to Specify in the Race field AND in the Ethnicity field, MicroMD PM includes the patient in the Unreported/Refused to Report Ethnicity section of the report. If a staff member enters Declined to Specify in the Race field BUT NOT in the Ethnicity field, MicroMD PM includes the patient in the Hispanic/Latino section of the report. If a staff member enters Declined to Specify in the Ethnicity field BUT NOT in the Race field, MicrOMD PM includes the patient in the Non-Hispanic/Latino section of the report. Section A: Deliveries and Birth Weight Section A reports on data for those babies born with low birth weight versus normal birth weight. It also reports on the women having the babies. You can find the pregnancy information for this section in the Pregnancy History section of the Patient Profile Detail tab of the Patient Detail window (Figure 6.2 on page 6.3). For those practices who also use MicroMD EMR: When you enter a pregnancy in this section in the PM, the system creates a new Pregnancy History record in the EMR. If you have a pregnancy created in the EMR, the system automatically completes the Pregnancy History section in the PM based on data entered in the EMR. There must be a check mark in the Prenatal User checkbox on the Patient Profile Detail tab for the user to appear in Section A of the report. The total in Column 1a will not equal the total of Column 1b+Column 1c+Column 1d. See page 7.3 for more details. Line 0: HIV Positive Pregnant Women The number in Line 0 in Section A reflects all of those patients where there is a check mark in the Patient is Pregnant and HIV Positive checkbox for the current pregnancy record. This checkbox is on the Pregnancy Detail window that displays when you click the Edit icon ( ) for the pregnancy record (on the Patient Profile Detail tab of the Patient Detail window). See Figure 6.3 on page 6.3. In addition, either the date entered in the First Prenatal Visit field or the date entered in the Delivery Date/ End Date field falls within the date range you enter in the Date of Service fields on the report options window. 7.2 MicroMD PM UDS Reporting Guide: Performance Year 2017

43 Section B: Controlling High Blood Pressure Health Outcomes and Disparities (Table 7) Line 2: Deliveries Performed by Health Center Provider The number in Line 2 in Section A reflects all of those patients in your practice where there is an active pregnancy record where the date entered in the Delivery Date/End Date field (Figure 6.3 on page 6.3) falls within the date range you enter in the Date of Service fields on the report options window. Remaining Lines of Section A The remaining lines of section A pertain to the race and ethnicity of your prenatal patients and detail about their births. Column 1a, Prenatal Care Patients and Referred Prenatal Care Patients Who Delivered During the Year In order for the patient to be counted in Column 1a on this report, the date displayed in the Delivery/ End Date field (Figure 6.3 on page 6.3) for the selected pregnancy falls within the date range you enter in the Date of Service fields on the report options window. Columns 1b through 1d, Live Births To be counted in Column 1b through Column 1d, MicroMD PM must find an entry in the Delivery Weight (grams) field (Figure 6.3 on page 6.3) on the pregnancy record. In addition, either Full-Term or Pre-Term must appear in the Description field. MicroMD PM then adds to the appropriate column on the report. You may be tempted to compare the total for Column 1a with the sum of Columns 1b, 1c, and 1d. These numbers are not related in this fashion. Column 1b through Column 1d only consider those pregnancy records where Full-Term or Pre- Term appear in the Description field while Column 1a also includes those pregnancy records for Stillbirth, etc. If there is no entry in the Delivery Weight (grams) field on the pregnancy record, it does not count in Column 1b through Column 1d, but the record does count for Column 1a. If there are multiple pregnancy records for the same Delivery/End Date (e.g., twins), the pregnancy only counts once for Column 1a, but each record counts individually for Column 1b through Column 1d. If there are multiple pregnancy records with the Delivery/End Date occurring within the date range entered in the Date of Service report option, the record will count multiple times in Column 1a, as well as Column 1b through Column 1d. Section B: Controlling High Blood Pressure (CMS165v5) The Clinical Quality Measure (CQM) reports on the Percentage of patients years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period. Section B of the Table 7 report mostly aligns with the CQM displayed in the heading to this section. The only difference is the UDS report stratifies the numbers based on race and ethnicity. See the Overview section on page 7.2 for details on finding race and ethnicity information. MicroMD PM UDS Reporting Guide: Performance Year

44 Health Outcomes and Disparities (Table 7) Section C: Diabetes: Hemoglobin A1c Poor Control If you are a MicroMD-PM only practice, the system pulls the hypertension data from your entries in the Clinical section of the Patient Detail window (on the Patient Profile Details tab). For MicroMD PM + EMR practices, the Clinical section of the Patient Detail window (on the Patient Profile Details tab) displays the patient s most recent data. For details on meeting the measure, click the Clinical Measures Data button and scroll to the bottom. Please refer to the MicroMD EMR Clinical Quality Measurement Calculations Guide: Performance Year 2017 for more details on how the system calculates each column. Column 2a (Total Patients 18 through 85 years of Age with Hypertension): Use the instructions for the Denominator in the CQM. Column 2b (Charts Sampled or EHR Total): In MicroMD PM, Column B is the same as Column A. Column 2c (Patients with HTN Controlled): Use the instructions for the Numerator in the CQM. Click here for a searchable list of codes used for this measure. Section C: Diabetes: Hemoglobin A1c Poor Control (CMS122v5) The Clinical Quality Measure (CQM) reports on the Percentage of patients years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period. Section C of the Table 7 report mostly aligns with the CQM displayed in the heading to this section. The only difference is the UDS report stratifies the numbers based on race and ethnicity, and the UDS report has an additional column of data for the number of patients whose HbA1c is less than 8%. See the Overview section on page 7.2 for details on finding race and ethnicity information. If you are a MicroMD-PM only practice, the system pulls the diabetic data from your entries in the Clinical section of the Patient Detail window (on the Patient Profile Details tab). For MicroMD PM + EMR practices, the Clinical section of the Patient Detail window (on the Patient Profile Details tab) displays the patient s most recent data. For details on meeting the measure, click the Clinical Measures Data button and scroll to the bottom. Please refer to the MicroMD EMR Clinical Quality Measurement Calculations Guide: Performance Year 2017 for more details on how the system calculates each column. 7.4 MicroMD PM UDS Reporting Guide: Performance Year 2017

45 Section C: Diabetes: Hemoglobin A1c Poor Control Health Outcomes and Disparities (Table 7) Column 3a (Total Patients 18 through 75 years of Age with Diabetes): Use the instructions for the Denominator in the CQM. Column 3b (Charts Sampled or EHR Total): In MicroMD PM, Column B is the same as Column A. Column 3d1 (Patients with HbA1c < 8%): There is no equivalent in the CQM. MicroMD PM pulls the data from the EMR and displays the number of patients from Column 3b for whom the most recent HbA1c test results value is below 8%. Column 3f (Patients with HbA1c > 9% Or No Test During Year): Use the instructions for the Numerator in the CQM. Click here for a searchable list of codes used for this measure. MicroMD PM UDS Reporting Guide: Performance Year

46 Health Outcomes and Disparities (Table 7) Section C: Diabetes: Hemoglobin A1c Poor Control *** THIS PAGE INTENTIONALLY LEFT BLANK FOR DOUBLE-SIDED PRINTING. *** 7.6 MicroMD PM UDS Reporting Guide: Performance Year 2017

47 Financial (Table 9) The UDS Table 9 report in the system allows the practice to generate a report based on patient related revenue and collects information on charges, collections and allowances. You can find the report under Aux > MicroMD CHC > UDS Reporting Tables > Financial - Table 9 from the main menu. Table 8.1 explains the fields in more detail. In this chapter, we cover: Report Options (page 8.1) Overview (page 8.1) Line 1 through Line 12 (page 8.2) Line 13 (page 8.3) In This Chapter Report Options To generate the report, you must first establish your reporting criteria. Only patients who meet the criteria on the report options appear on the report. Table 8.1 explains the options in detail. Table 8.1 Report Options Available for Financial - Table 9 Field Description Date of Service Location Select the service date range for which you want to generate a report. The default date is January 1 to December 31 of the previous year. You can change this as needed. From the Location drop-down, select the location(s) for which you want the report generated. MicroMD PM includes only those patients with sequences posted against the selected Location during the date range you specify in the Date of Service fields. Overview The Table 9 Financial report in MicroMD PM compiles information about the transactions posted against insurance plans based on the CHC Payor Category on each insurance plan. You can find this field on the Plan Detail window for the appropriate insurance (under Maint > Plan). MicroMD PM UDS Reporting Guide: Performance Year

48 Chapter 8. Financial (Table 9) Line 1 through Line 12 Figure 8.1 CHC Payor Category Line 1 through Line 12 Lines 1 through 12 on Table 9 total the transactions posted to patient accounts where the Service Date on the transaction falls within the date range you enter in the Date of Service fields on the report options window. The system breaks the data into those transactions posted to insurance carriers associated with the indicated Payor Category in the CHC Payor Category drop-down on the Plan Detail window (Figure 8.1). The sequence number for the sequence containing the transaction must be 1 or higher. MicroMD PM determines the dollar amounts that appear in Columns A, B and D for Line 1 through Line 12 in the following manner: Column A includes all transaction lines except those where the POS is one of the following: - P1 - PAYMENT CASH - PO - PAYMENT - OTHER - R1 - REFUND - W1 - WRITEOFF - PR - ADJ - REDUCE PAYMENT - WR - ADJ TO WRITEOFF - PI - ADJ - INCREASE PAYMENT - RR - ADJ TO REFUND - BI - BALANCE FORWARD - DEBIT - BR - BALANCE FORWARD - CREDIT AND the Bill flag for the transaction line is not set to N - Pat. Billing/Pat. Resp. AND the plan s CHC Payor Category field in not set to 13 - Self Pay Column B includes transaction lines where the POS is P1 - PAYMENT CASH or PO - PAYMENT OTHER. AND the Bill flag for the transaction line is not set to N - Pat. Billing/Pat. Resp. AND the plan s CHC Payor Category field in not set to 13 - Self Pay Column D includes transaction lines where the POS is WR - ADJ TO WRITEOFF or W1 - WRITEOFF AND the TOS for the procedure is II - INSURANCE - CHECK AND there is a check mark in the Allowances checkbox on the Procedure Detail window for the procedure 8.2 MicroMD PM UDS Reporting Guide: Performance Year 2017

49 Line 13 Chapter 8. Financial (Table 9) AND the Bill flag for the transaction line is not set to N - Pat. Billing/Pat. Resp. AND the plan s CHC Payor Category field in not set to 13 - Self Pay Line 13 Line 13 deals with self-pay patients, and in MicroMD PM, the system totals any amounts that are the patient s responsibility to pay and displays them in the appropriate column. Column A includes all transaction lines except those where the POS is one of the following: - P1 - PAYMENT CASH - PO - PAYMENT - OTHER - R1 - REFUND - W1 - WRITEOFF - PR - ADJ - REDUCE PAYMENT - WR - ADJ TO WRITEOFF - PI - ADJ - INCREASE PAYMENT - RR - ADJ TO REFUND - BI - BALANCE FORWARD - DEBIT - BR - BALANCE FORWARD - CREDIT AND: - the plan s CHC Payor Category field is 13 - Self Pay and the Bill flag for the transaction line is not set to N - Pat. Billing/Pat. Resp. OR - the Bill flag for the transaction line is N - Pat. Billing/Pat. Resp. Column B includes transaction lines where the POS is P1 - PAYMENT CASH or PO - PAYMENT OTHER. AND: - the plan s CHC Payor Category field is 13 - Self Pay and the Bill flag for the transaction line is not set to N - Pat. Billing/Pat. Resp. OR - the Bill flag for the transaction line is N - Pat. Billing/Pat. Resp. Column E includes transaction lines where the procedure code DOES NOT match the code selected in the Bad Debt Writeoff Code drop-down on the Practice Setup tab (under Aux > MicroMD CHC > Setup > Practice). AND the POS on the transaction is W1 - WRITEOFF or WR - ADJ TO WRITEOFF AND: - the plan s CHC Payor Category field is 13 - Self Pay and the Bill flag for the transaction line is not set to N - Pat. Billing/Pat. Resp. OR - the Bill flag for the transaction line is N - Pat. Billing/Pat. Resp. Column F includes transaction lines where the procedure code DOES match the code selected in the Bad Debt Writeoff Code drop-down on the Practice Setup tab (under Aux > MicroMD CHC > Setup > Practice). MicroMD PM UDS Reporting Guide: Performance Year

50 Chapter 8. Financial (Table 9) Line 13 *** THIS PAGE INTENTIONALLY LEFT BLANK FOR DOUBLE-SIDED PRINTING. *** 8.4 MicroMD PM UDS Reporting Guide: Performance Year 2017

51 Service Area Table MicroMD PM UDS Reporting Guide: Performance Year 2017 A.1

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53 Tables 3a, 3b, and 4 MicroMD PM UDS Reporting Guide: Performance Year 2017 B.1

54 B.2 MicroMD PM UDS Reporting Guide: Performance Year 2017

55 MicroMD PM UDS Reporting Guide: Performance Year 2017 B.3

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57 Table 5 MicroMD PM UDS Reporting Guide: Performance Year 2017 C.1

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59 Table 6a MicroMD PM UDS Reporting Guide: Performance Year 2017 D.1

60 D.2 MicroMD PM UDS Reporting Guide: Performance Year 2017

61 Table 6b MicroMD PM UDS Reporting Guide: Performance Year 2017 E.1

62 E.2 MicroMD PM UDS Reporting Guide: Performance Year 2017

63 MicroMD PM UDS Reporting Guide: Performance Year 2017 E.3

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65 Table 7 MicroMD PM UDS Reporting Guide: Performance Year 2017 F.1

66 F.2 MicroMD PM UDS Reporting Guide: Performance Year 2017

67 Table 9 MicroMD PM UDS Reporting Guide: Performance Year 2017 G.1

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