Telehealth Impact on 2021 Uniform Data System (UDS) Clinical Measure Reporting
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Telehealth Impact on 2021 Uniform Data System (UDS) Clinical Measure Reporting
Purpose: • The table is intended to help health centers determine how services to patients provided
via telehealth should be considered for the three measure components.
• This guidance applies only to UDS clinical measure denominator, numerator, and exclusion
reporting on Tables 6B and 7.
• This crosswalk applies the Centers for Medicare & Medicaid Services (CMS) guidance on
telehealth visits to electronic clinical quality measure (eCQM) reporting standards.
• This is not intended to provide guidance on federal and state regulations or restrictions on
the use of telehealth.
Requirement: • Clinical care provided to health center patients is reported in the UDS.
• Health centers are to identify the number of patients meeting each measure's criteria
in three components:
• Denominator: Patients who fit the detailed criteria described for inclusion in the specific
measure to be evaluated.
• Numerator: Patients (included in the denominator) that meet the measurement
standard for the specified measure.
• Exclusions/Exceptions: Patients who should not be included in the denominator.
Table Notes: • Each of the UDS clinical measures are included as separate rows, with their corresponding
CMS eCQM number.
• Some examples (not all inclusive) of visit types are included.
Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System
(HCPCS) codes used to identify eligible patient visits used for identification of a
patient for the denominator need to be identified by reviewing the eCQM criteria and codes directly.
• Exclusions are generally able to be determined through characteristics outside of a visit.
• Verification of already performed/completed services does not require a visit.
Column
Considerations: Denominator:
• This column is limited to defining whether patients whose only visit(s) during the year are
provided via telehealth are to be included.
Numerator:
• This column considers activity of all patients included in the denominator, which may
include in-person and/or telehealth visits.
• Verification of completed services can be done outside of a visit.
• For example, a mammogram cannot be completed via telehealth. However, if the patient
had a mammogram performed during the measurement period (or identified timeframe)
and documentation is included in the patient record, the patient record could be
considered compliant for the Breast Cancer Screening measure.
• To meet the measurement standard, review the associated eCQM guidance. Some require
the service to be performed by, paid for, or approved by the health center provider, while
others permit service completion by any provider as long as the service is in the specified
Last updated: July 1, 2021timeframe, meets the measure requirements, and is documented in the patient record.
Resources: • Calendar Year 2021 UDS Manual
• CMS Telehealth Guidance
• UDS Support Line
• Please visit the Center for Connected Health Policy for important telehealth policy issues and key
telehealth policy resources.
Last updated: July 1, 2021Telehealth Impact on 2021 Uniform Data System (UDS) Clinical Measure Reporting
Note: Items highlighted in pink are intended to draw attention to measure components that do not permit services via telehealth or by external providers.
Do documented services
Include patients with Can service, test, or procedure
Clinical Measure performed by external providers
telehealth only visits be done by telehealth to meet
Name, eCQM Illustrative Examples (not paid for or performed by the
on UDS Tables 6B UDS Tables 6B and 7, Columns
Code, UDS Table, of Types of Visits health center) count in UDS
and 7, Column A C or F (Numerator),
and UDS Section Tables 6B and 7, Columns C or F
(Denominator)? requirements?
(Numerator)?
No. Prenatal care
patients are
defined based on a
comprehensive in-
person prenatal
physical exam.
• OB/GYN routine Prenatal care
Early Entry into
check up patients
Prenatal Care, no Yes. Trimester of entry may be
• Physical with established in the Yes
eCQM, Table 6B, identified in this way.
primary care prior year (through
Lines 7-9
provider (PCP) a comprehensive
in-person exam)
and only seen
through telehealth
in the current year
should be included.
Childhood No. Administration of
• Well-child visits for
Immunization immunizations are not
newborns
Status, Yes acceptable in this way. These Yes
• Acute pain or
CMS117v9, Table services cannot be conducted
illness
6B, Line 10 via telehealth.
• Physical with PCP
Cervical Cancer • OB/GYN routine No. Cervical cytology/HPV
Screening, check up testing are not acceptable in
• Acute pain or Yes this way. These services Yes
CMS124v9, Table
illness cannot be conducted via
6B, Line 11
• Signs or symptoms telehealth.
of conditions
• Physical with PCP
Breast Cancer • OB/GYN routine No. Mammograms are not
Screening, check up acceptable in this way. These
• Acute pain or Yes Yes
CMS125v9, Table services cannot be conducted
illness
6B, Line 11a via telehealth.
• Signs or symptoms
of conditions
Last updated: July 1, 2021Do documented services
Include patients with Can service, test, or procedure
Clinical Measure performed by external providers
telehealth only visits be done by telehealth to meet
Name, eCQM Illustrative Examples (not paid for or performed by the
on UDS Tables 6B UDS Tables 6B and 7, Columns
Code, UDS Table, of Types of Visits health center) count in UDS
and 7, Column A C or F (Numerator),
and UDS Section Tables 6B and 7, Columns C or F
(Denominator)? requirements?
(Numerator)?
Weight No. Height and weight are to be
No. Height and weight are not
Assessment and performed or paid for by health
acceptable in this way.
Counseling for • Well-child visits center staff.
Nutrition and • Sport or school
Physical Activity activity physical Yes
• Acute pain or No. Counseling for physical
for Children and Yes. Counseling for physical
illness activity and nutrition are to be
Adolescents, activity and nutrition are
CMS155v9, Table performed or paid for by health
acceptable in this way.
6B, Line 12 center staff.
No. Height and weight are to be
Preventive Care No. This screening No. Height and weight are not performed or paid for by health
and Screening: • Physical with PCP measure requires acceptable in this way. center staff.
Body Mass Index • Acute pain or therapy, treatment,
(BMI) Screening illness or assessment that
and Follow-Up • Signs or symptoms cannot be
No. Follow-up plan is to be
Plan, CMS69v9, of conditions conducted via Yes. Follow-up plan is
performed or paid for by health
Table 6B, Line 13 telehealth. acceptable in this way.
center staff.
Preventive Care
• Physical with PCP No. Screening for tobacco use is to
and Screening:
• OB/GYN routine be performed or paid for by health
Tobacco Use:
check up Yes. Screening for tobacco use center staff.
Screening and
• Acute pain or Yes and cessation intervention are
Cessation
illness acceptable in this way.
Intervention, Yes. Cessation intervention may
• Signs or symptoms
CMS138v9, Table be referred out.
of use
6B, Line 14a
Statin Therapy
for the • Physical with PCP
Prevention and or specialist
Yes. Prescription or an order
Treatment of • Acute pain or
Yes for statin therapy is acceptable Yes
Cardiovascular illness
in this way.
Disease, • Care for chronic
CMS347v4, Table condition
6B, Line 17a
Last updated: July 1, 2021Do documented services
Include patients with Can service, test, or procedure
Clinical Measure performed by external providers
telehealth only visits be done by telehealth to meet
Name, eCQM Illustrative Examples (not paid for or performed by the
on UDS Tables 6B UDS Tables 6B and 7, Columns
Code, UDS Table, of Types of Visits health center) count in UDS
and 7, Column A C or F (Numerator),
and UDS Section Tables 6B and 7, Columns C or F
(Denominator)? requirements?
(Numerator)?
Ischemic
Vascular Disease • Physical with PCP
(IVD): Use of or specialist
Yes. An order for medication
Aspirin or • Acute pain or
Yes (of aspirin or antiplatelet) is Yes
Another illness
acceptable in this way.
Antiplatelet, • Care for chronic
CMS164v7, Table condition
6B, Line 18
No. Procedures (Flex Sig and
Colonoscopy) and diagnostic
• Physical with PCP studies (CT colography) are not Yes
Colorectal Cancer • OB/GYN routine acceptable in this way. These
Screening, check up services cannot be conducted
• Acute pain or Yes via telehealth.
CMS130v9, Table
illness
6B, Line 19
• Signs or symptoms
of conditions Yes. An FOBT or FIT-DNA that
is mailed and processed by a Yes
lab are acceptable.
• Physical with PCP
or specialist Yes. At the discretion of the
• OB/GYN routine healthcare and prescribing
HIV Linkage to provider, the medical visit may
check up
Care, no eCQM, Yes be conducted and HIV Yes
• Acute pain or
Table 6B, Line 20 treatment are acceptable in
illness
• Care for chronic this way.
condition
No. Patient attestation or self-
report of HIV results is not
• Physical with PCP
• OB/GYN routine acceptable in this way.
HIV Screening, check up
CMS349v3, Table • Acute pain or Yes Yes
6B, Line 20a illness Yes. HIV self-tests may be
• Signs or symptoms acceptable; the provider must
of conditions receive documentation of the
lab test result.
Preventive Care No. Screening for depression and
• Physical with PCP
and Screening: development of follow-up plan
• OB/GYN routine
Screening for Yes. Screening for depression are to be performed or paid for
check up
Depression and and follow-up plan are by health center staff.
• Acute pain or Yes
Follow-Up Plan, illness acceptable in this way.
CMS2v10, Table Yes. Follow-up plan may include a
• Signs or symptoms
6B, Line 21 referral to another provider.
of conditions
Last updated: July 1, 2021Do documented services
Include patients with Can service, test, or procedure
Clinical Measure performed by external providers
telehealth only visits be done by telehealth to meet
Name, eCQM Illustrative Examples (not paid for or performed by the
on UDS Tables 6B UDS Tables 6B and 7, Columns
Code, UDS Table, of Types of Visits health center) count in UDS
and 7, Column A C or F (Numerator),
and UDS Section Tables 6B and 7, Columns C or F
(Denominator)? requirements?
(Numerator)?
• Physical with PCP
Depression
or specialist Yes. Identification of remission
Remission at
• Acute pain or achieved is acceptable in this
Twelve Months, Yes Yes
illness
CMS159v9, Table way.
• Care for chronic
6B, Line 21a
condition
Dental Sealants • Routine exam with
for Children dentist No. Application of sealants is
between 6–9 • Acute pain or not acceptable in this way.
Yes Yes
Years, illness These services cannot be
CMS277v0, Table • Signs or symptoms conducted via telehealth.
6B, Line 22 of risk factors
Low Birth • Postnatal care visit
Weight, no • OB/GYN routine
Yes Yes. Birth weights may be Yes
eCQM, Table 7, check up
• Physical with PCP identified in this way.
Section A
No. Patient self-report blood
• Physical with PCP pressure is not acceptable in
Yes. Blood pressure is to be
Controlling High or specialist this way.
performed, paid for, or approved
Blood Pressure, • Acute pain or
Yes by a health center provider or
CMS165v9, Table illness Yes. Blood pressure through
• Care for chronic provider delegate and documented
7, Section B remote monitoring device only
condition in the patient health record.
is acceptable in this way.
Diabetes: • Physical with PCP
Hemoglobin A1c Yes. HbA1c is to be performed, paid
or specialist No. HbA1c lab test is not
(HbA1c) Poor for, or approved by a health center
Control (>9 • Acute pain or acceptable in this way. These
Yes provider or provider delegate and
percent), illness services cannot be conducted
• Care for chronic documented in the patient
CMS122v9, Table via telehealth.
condition health record.
7, Section C
Note: Items highlighted in pink are intended to draw attention to measure components that do not permit services via telehealth or by external providers.
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