HRSA Announces Changes to Uniform Data System Reporting

AAFCPAs would like to make Federally Qualified Health Center clients aware of recent updates made by the Health Resources Services Administration (HRSA) to the 2023 Uniform Data System (UDS) report, due February 15, 2024.

Updates to UDS Reporting

HRSA announced changes to how data on Table 6A are now defined including updates to applicable ICD-10-CM Codes, Value Set Object Identifiers (OID), CPT4/I/PLA, and CPCS Codes. Value sets from the Value Set Authority Center (VSAC) have also been added to diagnosis and service codes, which notably enhances transparency by making use of federal standards to ensure consistency across federal reporting and to align reported information in Table 6A with that used elsewhere on the UDS.

Also, changing this year are electronic-specified clinical quality measures (eCQMs), aligning Tables 6B and 7 with the latest Centers for Medicare & Medicaid Services eCQMs.

Changes to Existing Reporting

Specifications for eCQM Tables 6b and 7 Measures have changed, with UDS now including and evaluating patients for the denominator, demonstrating at least one eligible countable visit versus at least one medical visit. The administration has also made specified changes to seven eCQMs as follows:

  1. The Body Mass Index (BMI) Screening and Follow-Up Plan measure numerator changed from a 12-month requirement for BMI documentation to one during the measurement period.
  2. The Tobacco Screening measure numerator now allows for tobacco cessation intervention during the measurement period or in the six months prior to that measurement period if the patient is identified as a tobacco user. Use of e-cigarettes and other electronic nicotine delivery systems will now be considered tobacco use. Lastly, Hospice care has been added as a denominator exclusion.
  3. The Colorectal Cancer Screening measure denominator changed from age 50–75 to age 45–75.
  4. The Depression Screening measure changed from follow-up, if needed, on the date of visit to follow-up on the date of or up to two days after the date of the visit.
  5. Statin Therapy for the Prevention and Treatment of Cardiovascular Disease denominator changed from all patients who were previously diagnosed with or currently have an active diagnosis of ASCVD (including an ASCVD procedure) to all patients with an active diagnosis of ASCVD or whoever had an ASCVD procedure.
  6. The final age to include in the Weight Assessment and Counseling measure has been changed from age 16 to 17.
  7. The following denominator exclusion has been added to the hypertension measure: Patients ages 81 and older by the end of the measurement period with an indication of frailty for any part of the measurement period.

A change was also made to the reporting of opioid use disorder treatment in Appendix E: Other Data Elements, specifically Medication Assisted Treatment (MAT) is now referred to as Medications for Opioid Use Disorder (MOUD).

New Data Reported

There are four areas of new data reporting. First, Tables 3B and 7 have been updated for several race and ethnicity categories.

Second, Table 5 Lines 23a–23d have been added to capture detailed data on pharmacy personnel as follows:

  • 23a: Pharmacists
  • 23b: Clinical Pharmacists
  • 23c: Pharmacy Technicians
  • 23d: Other Pharmacy Personnel

Third, Table 6A, Line 26e: Childhood Development Screenings and Evaluations, Column A denotes the number of visits at which the above childhood development services were provided and Column B denotes the number of patients who have had one or more visits where the above childhood development services were provided.

Fourth, an update was made to Table 9E Line 1P, Expanding COVID-19 Vaccination (ECV) along with other COVID-19-Related Funding from BPHC, which was previously reported on Line 1p and is now reported on Line 1p2.

Full context may be found on under Uniform Data System (UDS) Program Assistance Letters | Bureau of Primary Health Care.

AAFCPAs advises that clients allow sufficient time for implementation and data capture. We also recommend that clients map appropriate systems to reflect changed data points while making sure appropriate information is correctly captured. FQHCs will want to work with their electronic health record vendor to update software, if needed, and will need to continually educate staff involved with UDS reporting on these changes.

AAFCPAs can help to ensure optimal use of reporting systems to gather and measure requisite information.

If you have questions, please contact Robert Constantino, CPA, MSA, Director at 774.512.4213 or, Matthew Hutt, CPA, CGMA, Partner at 774.512.4043 or—or your AAFCPAs Partner.

About the Authors

Rob is responsible for planning and executing financial audits for sophisticated nonprofit organizations, including: community health centers, charter schools, behavioral health agencies, community development corporations, and community development financial institutions. Rob has significant experience working with audits in accordance with Uniform Guidance/Single Audit Standards and the Massachusetts Uniform Financial Report. Rob also has extensive experience with ERISA Employee Benefit Plan Audits, as well as the preparation and filing of the Federal Form 990 and Form 990-T unrelated business income tax (UBIT) returns.
Matthew Hutt CPA
Matt leads AAFCPAs’ Healthcare Division, providing assurance, tax and advisory solutions for Federally Qualified Health Centers (FQHCs), behavioral health providers, home care agencies and hospices, nursing homes, and senior care living centers. Matt advises healthcare providers on consolidation and coordination of care, including the integration of behavioral health into the primary care delivery system. He also provides consulting solutions for providers transitioning to new value-based reimbursement models, and data driven patient care, including: developing business process and controls for collecting and advantaging data to provide analysis on: provider activity, delivery of care, and analysis of efficiency & cost effectiveness. Matt is also highly-sought after for his knowledge on issues related to affordable housing developers with requirements related to the US Department of Housing and Urban Development, MassHousing, Low Income Housing Tax Credits, Historical Tax Credits and New Markets Tax Credits.