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

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

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

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

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

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

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

Instructions for reporting Encounters - Column (a).

LINES 1 – 20: Diagnostic Data.

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

LINES 21 – 34: Service Data.

Encounters by Selected Tests/Screenings/Preventive and Dental Services ( Lines 21-34). Report the total number of encounters at which one or more of the listed diagnostic tests, screenings, and/or preventive services were provided. Note that codes for these services may either be diagnostic (ICD-9) codes or procedure ( ADA or CPT-4) codes. During one encounter more than one test, screening or preventive service may be provided, in which case, each would be counted.

• One encounter may involve more than one of the identified services in which case each should be reported. For example, if during an encounter both a Pap test and an HIV test were provided then an encounter would be reported on both lines 21 and 23.
• If a patient receives multiple immunizations at one visit, only one encounter should be reported.
• Services may be reported in addition to diagnoses. A hypertensive patient who also receives an HIV test would be counted once on the hypertension line 11 and once on line 21, HIV test.
• If a patient had more than one tooth filled, only one encounter for restorative services should be reported, not one per tooth.

Instructions for reporting Patients - Column (b)

LINES 1 – 20: Diagnostic Data.

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

LINES 21 – 26: Services Data.

Patients by Selected Diagnostic Tests/Screenings/Preventive Services -- Report patients who have had at least one encounter during the reporting period for the selected diagnostic tests, screenings, and/or preventive services listed on Lines 21-26. If a patient had a Pap test and contraceptive management during the same encounter, this patient would be counted on both Lines 23 and 25 in Column B. Regardless of the number of times a patient receives a given service, they are counted once and only once on that line in Column B. For example, an infant who has multiple well child visits in the year has each visit reported in column A, but is counted only once in column B.

LINES 27 – 34: Dental Services Data.

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

Questions and Answers for Table 6A

•  Are there any changes to the table this year?

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

•  If a case manager or health educator serves a patient who is, for example, a diabetic, we often show that diagnostic code for the visit. Should this be reported on Table 6A?

No. Report only encounters with medical, dental and behavioral health providers on Table 6.

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

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

•  Some diagnostic and/or procedure codes in my system are different from the codes listed. What do I do?

It is possible that information for Table 6 is not available using the codes shown because of idiosyncrasies in state or clinic billing systems. Generally, these involve situations where (a) the state uses unique billing codes, other than the normal CPT code, for state billing purposes (e.g., EPSDT) or (b) internal or state confidentiality rules mask certain diagnostic data. The following provides examples of problems and solutions.

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

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