Inclusion criteria for UDS quality measures

For inclusion in a quality measure on UDS Table 6B or 7, patients must have both a “UDS countable visit”1 and also a “qualifying visit,” which is defined differently for each measure. The UDS Manual documents these requirements as follows:

For each of the measures, specifically assess patients seen during the year for a UDS countable visit AND CQM qualifying encounter, as specified in the measure criteria.

The UDS Manual also notes:

Patients seen only for care in an urgent care setting, patients seen only once for acute care, patients seen only for specialty care, and/or patients who have since left the practice are not to be excluded from the measures.

Out of scope locations

Some health centers provide care at what HRSA calls “out of scope” locations. These are locations which do not appear on your health center’s Form 5B or Form 5C. A visit at an out of scope location does not qualify a patient for inclusion in a UDS quality measure.2

To remove out of scope visits from UDS measure calculations, set rdm.visits.hrsa_in_scope_location to false. Typically, the best way to accomplish this is to set hrsa_in_scope_location to the appropriate values in the Locations data element, then pull that information into the mapping for the Visits data element.

Most health centers do not provide care at out of scope locations and can safely ignore these mapping considerations, since the default value for rdm.visits.hrsa_in_scope_location is TRUE.

  1. In Relevant, the concept of a “UDS qualifying visit” is often referred to as a “UDS universe” visit. ↩

  2. We clarified this in consultation with HRSA’s UDS Support Center; here are the receipts. ↩