Form Electronic Data Co Electronic Data Co Electronic Data Collection Tool

ATTACHMENT F
PBHCI ELECTRONIC DATA COLLECTION TOOL FOR GRANTEE
REGISTRY/ELECTRONIC HEALTH RECORDS (EHRs)

This page has been left blank for double-sided copying.

Cohort 8 Grantee Electronic Record System Data Request for National Cross-Site PBHCI Evaluation
Purpose of Data The submission of this data is critical to help SAMHSA understand the services that PBHCI clients receive. We will use this data to monitor the delivery of care and calculate
clinical quality measures. Only Cohort 8 grantees are being asked to submit this data.
Request

General
Directions

This spreadsheet lists the data elements/variables to extract from your EHRs, clinical registry, or other electronic systems. You may extract each data element from the
most reliable data source. We are not prescriptive about the data source. Rather, each grantee should determine the most reliable data source for each variable. Many of
the variables are intended to capture services provided by your PBHCI program or clinic. For these variables, do not limit reporting only to services that were delivered by
staff/providers who are directly supported by the PBHCI grant. Rather, report all services provided by your PBHCI program. Our goal is to capture all services that PBCHI
clients receive from the PBHCI program.

If possible, please submit your file(s) following the structure in the Example File Layout tab of this workbook. In this example, each row represents a unique client

Structure of (identified using the TRAC identifier). The columns represent the requested variables. If this format is problematic, we will accept other formats that are organized
Data Submission according to the client's TRAC identifier. If combining these variables into a single file is problematic, you may submit separate files that contain a subgroup of variables.
Please submit files in Excel (xls, xlsx, csv), SAS, Stata, or SPSS formats.

Timeframe of
Data Request

Please submit data that contains data for all clients enrolled in the PBHCI program through September 30, 2016. Only report services delivered AFTER PBHCI enrollment;
we are not asking you to report services delivered before the client enrolled in PBHCI. We recognize that many grantees did not begin client enrollment until late 2015 or
2016. Thus, your first reporting period may actually begin later than September 2015 to correspond with the date that the first consumer was enrolled in the program.
Subsequent data requests will cover each quarter and follow a set reporting schedule that coincides with submission of the IPP indicators. You can submit files in the
future that only cover the specified time period or submit a cumulative file that contains all data from the beginning of the grant period.

We have provided variable names. However, if you find it easier, you can submit the data using variable names from your system(s) and provide Mathematica with a
crosswalk of variable names. Several of the services captured in this spreadsheet may be billable for some grantees. For those services, you may find it helpful to map them
Variable Names to billing codes. However, DO NOT limit reporting of these services only to those that are billable. Report both billable and non-billable services. For some variables, we
and Service have provided examples of billing codes that are frequently used for services but this is not an exhaustive list. Grantees may use other billing codes. Reporting of
billing/procedure codes is optional. Please report if such codes are available/already in use and easily accessible in your systems. However, we are not asking you to assign
Codes
services to codes if codes do not already exist. We recognize that there is variation across grantees and states in service definitions. We have attempted to provide
clarifying definitions of each variable. Please contact us if you have questions about whether a particular service should be included.

Where to
Submit Data

Do NOT email data files. Please use the password assigned to your program to submit the data via the secure website:
https://www.pbhcieval.com/Grantee/SitePages/Home.aspx

Where to Get
Help

Contact Mathematica with any questions about this request at [email protected] or 866-504-9640. Also contact Mathematica if you cannot access the
website to submit the data.

I. Client Demographics
Variable
trac_id
birth
mdx1
mdx2
mdx3
mdx1_s
mdx2_s
mdx3_s
pdx1
pdx2
pdx3
pdx1_s
pdx2_s
pdx3_s

gender

Description

Format

Values

TRAC identification number

Char

Integer

Year of birth

Num

yyyy

Report the client's year of birth. We will use this information to verify
an accurate match to the TRAC data.

Primary mental health and
substance abuse diagnoses

Num

DSM, ICD-10 codes, or other

Secondary mental health and
substance abuse diagnoses

Num

DSM, ICD-10 codes, or other

Primary physical health
diagnoses

Num

DSM, ICD-10 codes, or other

Secondary physical health
diagnoses

Num

DSM, ICD-10 codes, or other

Client gender

Num

0 = Male
1 = Female
2 = Transgender
3 = Other

4 = Refused/unknown

race

hispan

Definition of Variables
Use the same identification number used in the TRAC system to
identify clients in this spreadsheet.

Client race

Num

Is the client Hispanic or
Latino(a)?

Num

0 = Black or African American
1 = White
2 = Asian
3 = American Indian
4 = Alaska Native
5 = Native Hawaiian or other Pacific Islander
99 = Unknown
0 = Not Hispanic or Latino(a)
1 = Hispanic or Latino(a)
99 = Unknown

Report all of the client's primary/principal and secondary mental
health and substance abuse diagnoses at your clinic using either DSM
or ICD-10 codes; we will accept all codes. You do not need to list the
diagnoses in any specific order. If you cannot list all diagnoses, please
attempt to report the most frequent primary/principal and secondary
diagnoses for the client.
Report all of the client's primary/principal and secondary physical
health diagnoses at your clinic using either DSM or ICD-10 codes; we
will accept all codes. You do not need to list the diagnoses in any
specific order. If you cannot list all diagnoses, please attempt to report
the most frequent primary/principal and secondary diagnoses for the
client.
Report client's gender. We will use this information to verify an
accurate match to the TRAC data. If your organization uses other
categories, such as transgender, you can may submit the data using
those categories and provide Mathematica with a variable crosswalk.

Report client's race. We will use this information to verify an accurate
match to the TRAC data. These race categories are the same ones used
in the TRAC system. If your organization uses other race categories, we
will accept those (please label the categories in your data submission).

Report if client is Hispanic. We will use this information to verify an
accurate match to the TRAC data. Hispanic ethnicity is reported in
TRAC.

II. Services Provided to PBHCI Clients by Your Clinic/Agency
The data elements in this section capture visits or encounters at your clinic/agency. These are not limited to visits/encounters with providers who are directly supported by the PBHCI grant. In most situations, these visits are face-to-face
meetings with clients. In some circumstances the client may be present via telephone or video. NOTE: For illustration, we have limited the number of rows in the spreadsheet to 5 observations/encounters for each variable. If there are
more visit dates than rows available in the spreadsheet, please include the additional dates in your submission and number them sequentially.

Variable

Date of Service (either
mm/dd/yyyy or mmddyyyy is
acceptable)

mm_1

mmddyyyy

mm_2

mmddyyyy

mm_3

mmddyyyy

mm_4

mmddyyyy

mm_5

mmddyyyy

cc_1

mmddyyyy

cc_2

mmddyyyy

cc_3

mmddyyyy

cc_4

mmddyyyy

cc_5

mmddyyyy

mh_1

mmddyyyy

mh_2

mmddyyyy

mh_3

mmddyyyy

mh_4

mmddyyyy

mh_5

mmddyyyy

Definition of Encounter Types

Example Billing Codes (NOTE: these codes are only provided for
illustration as guidance, do not limit your reporting to these codes.
Grantees may use various procedure codes and not all services
below are billable.)

Please report all dates of service and service codes for medication management services provided directly to the client. Medication
management services are intended to ensure the client receives and uses medications appropriately and avoids drug interactions, side
effects, and other negative outcomes.
Examples of medication management services may include (but are not limited to):
(1) discussions with client to assess his/her medication needs and/or complications
(2) development or updating of medication management plan in collaboration with the client
(3) discussions with client of medication use and side effects
(4) other direct individualized education for clients about safe and effective medication use
In medication management, the healthcare professional and client are both actively involved (e.g. discussing a client's medication during a
team meeting in the absence of the client is NOT considered medication management). Medication management must be provided by
qualified professional; these qualifications may vary depending on the medication management activity and is not limited to pharmacists,
physicians, or nurses. Medication management is not limited to prescribed medications but also includes over the counter medications.

The following codes are often used for medication management
services: E&M codes 99201–99255, 99281–99285, 99304–99337, or
99341–99350 are typically used by a physician or psychiatric nurse
providing psychotropic pharmacologic management WITHOUT
psychotherapy services. 99201–99255, 99281–99285,
99304–99337, or 99341–99350 + 90833, 90836, or 90838 E&M
codes, used in conjunction with code 90833, 90836, or 90838 for
physician or psychiatric nurse providing psychotropic
pharmacologic management WITH psychotherapy services.
Services provided by pharmacists using CPT codes 99605, 99606,
99607 are considered medication management. Grantees may bill
for similar services using different codes.

Please provide dates and service codes for case management (CM) and/or care coordination (CC) services. Case management and care
coordination can be provided by a range of staff (case managers, care managers, patient navigators, peer support staff, etc.). Case
management and care coordination could occur in the clinic or elsewhere in the community (for example, the client's home).

The following CPT codes are often used to bill for care
management or case management: 99490, 98966, 98967, 98968,
99490, 99495, 99496

Please provide dates and service codes for psychotherapy visits. These visits may include various forms of psychotherapy (group or
individual) or talk therapy that occurs with the client. Psychotherapy visits are not restricted to visits with psychiatrists but may include a
range of therapists (counselors, psychologists, social workers, etc.).

The following CPT codes are commonly used for psychotherapy
with the client: 90832, 90833, 90834, 90836, 90837, 90838, 90845,
90846, 90849, 90853, 90875, 90876, and 90880.

ps_1

mmddyyyy

ps_2

mmddyyyy

ps_3

mmddyyyy

ps_4

mmddyyyy

ps_5

mmddyyyy

ph_1

mmddyyyy

ph_2

mmddyyyy

ph_3

mmddyyyy

ph_4

mmddyyyy

ph_5

mmddyyyy

tpl_1

mmddyyyy

tpl_2

mmddyyyy

tpl_3

mmddyyyy

tpl_4

mmddyyyy

tpl_5

mmddyyyy

Please report dates and service codes for peer support services. Peer support services provide an opportunity for consumers in recovery to
assist other consumers in achieving recovery through social support, empowerment, skill building, role modeling, and activation. Grantees
may employ different types of peer support staff (for example, certified vs. not certified peer specialists). Report all peer support services
H0038 is a HCPCS code used for peer support services.
with all types of peer support staff. Peer support visits may or may not be a billable service in your state. NOTE: Do NOT report care
coordination or wellness services delivered by peer support staff for this variable. Rather, this variable is intended to capture all other peer
support services that are not captured through the care coordination and wellness service variables.

Please report dates and service codes for physical health or primary care visits provided by your clinic or PBHCI program. These include
preventative and acute care visits for physical health conditions. These services are typically provided by primary care providers (e.g. MD,
99214, 99204, and 99211–99215 are examples of CPT codes for
DO, NP, PA, RN). Include any physical health or primary care services provided by clinicians who are formally or informally affiliated with
office or other outpatient visit for the evaluation and management
your program (including those for whom you have formal MOUs/agreements and others who you consider partner providers under the
of an establishing patient or follow-up visit .
PBHCI program). For this variable, do NOT include services that are provided by clinicians unaffiliated with your PBHCI program (a separate
variable below captures these services).

Please report all dates and service codes (if applicable) for developing or updating the treatment plan. The process of working directly with
the client to identify his/her problems/needs, establish treatment goals, and decide what treatment methods will be used to address
problems/needs and work toward goals. Report the date on which the treatment plan was developed or formally updated. (NOTE: Some HCPCS code H0032 and CPT code 90885 are used for initial
grantees engage in joint treatment planning between behavioral health and physical health providers whereas others conduct somewhat treatment plan development or update/review.
separate treatment planning. Please report treatment planning that is captured in your systems and ideally includes both behavioral health
and physical health treatment goals).

III. Wellness Services Provided by Your PBHCI Program
Report clients' participation in the RFA-mandated wellness programs offered by or affiliated with your PBHCI program. These may be individual encounters or participation in
group activities.
Variable

Date of Wellness Service
(either mm/dd/yyyy or
mmddyyyy is acceptable)

wellsm_1

mmddyyyy

wellsm_2

mmddyyyy

wellsm_3

mmddyyyy

wellsm_4

mmddyyyy

wellsm_5

mmddyyyy

wellnutr_1

mmddyyyy

wellnutr_2

mmddyyyy

wellnutr_3

mmddyyyy

wellnutr_4

mmddyyyy

wellnutr_5

mmddyyyy

welltob_1

mmddyyyy

welltob_2

mmddyyyy

welltob_3

mmddyyyy

welltob_4

mmddyyyy

welltob_5

mmddyyyy

Definition of Services

Example Billing Codes (NOTE: This is not an exhaustive list of codes.
Grantees may use various procedure/billing codes. Some wellness
services are not billable). Only report participation in the evidencebased interventions listed.

Grantees had the option to implement Whole Health Action
Management (WHAM), the Health and Recovery Peer Program
Report all dates on which client participated in your selected
evidence-based chronic disease self-management intervention(s). (HARP) or the Stanford Chronic Disease Self-Management
This can include individualized or group activities or sessions.
(CDSM). Please only report participation in these evidencebased interventions.

Report all dates on which client participated in your selected
evidence-based nutrition, diet, or exercise intervention(s)
indicated in your grant application. This can include individualized
counseling or group activities or sessions. Grantees were asked to
select from the following: Nutrition and Exercise for Wellness and
Recovery, Diabetes Awareness and Rehabilitation Training,
Solutions for Wellness, In SHAPE, Stoplight Diet, Weight Watcher,
and ACHIEVE. Only report participation in these interventions or
other diet, nutrition, or exercise interventions approved by your
GPO .

CPT codes 97802, 97803, 97804 are often used for individual and group
medical nutrition therapy procedures. CPT code 96153 is often used
for exercise intervention services (Please note that this is a general
code that can be used for other behavioral health interventions as
well).

Report all dates on which client participated in your selected
evidence-based tobacco cessation intervention(s) indicated in
your grant application. This can include individualized counseling
or group activities/sessions. Grantees were asked to select from
the following: DIMENSIONS Tobacco Free Program (formerly
known as Peer-to-Peer Tobacco Dependence Recovery Program),
Learning about Healthy Living, or Intensive Tobacco Dependence
Intervention. Only report participation in these interventions or
other tobacco interventions approved by your GPO .

CPT codes 99406, 99407 can be used for behavior change
interventions, individual services related to smoking cessation
counselling.

IV. Referrals to Providers Outside Your PBHCI Program
Report referrals to providers who are NOT involved in implementing the PBHCI program. These are typically specialists or other providers in the community who are not
affiliated with the PBHCI program. Do NOT report internal referrals to PBHCI providers.
Variable

Date of Referral (either
mm/dd/yyyy or mmddyyyy is
acceptable)

wt_1

mmddyyyy

wt_2

mmddyyyy

emh_1

mmddyyyy

emh_2

mmddyyyy

sa_1

mmddyyyy

sa_2

mmddyyyy

tcs_1

mmddyyyy

tcs_2

mmddyyyy

eph_1

mmddyyyy

eph_2

mmddyyyy

Definition of Variables

Report dates of external referrals for obesity, weight management, nutrition, or exercise. Do not report referrals to services or programs
offered by your PBHCI program. Only report referrals to external providers.
Report dates of referrals for mental health services. Do not report referrals to services or programs offered by your PBHCI program. Only
report referrals to external providers.
Report dates of referrals for substance abuse services. Do not report referrals to services or programs offered by your PBHCI program. Only
report referrals to external providers.
Report dates of referrals for tobacco cessation. Do not report referrals to services or programs offered by your PBHCI program. Only report
referrals to external providers.
Report dates of referrals for physical health care. Do not report referrals to services or programs offered by your PBHCI program. Only
report referrals to external providers.

V. Medications
Report all medications (prescribed and over the counter) within the designated time period. These medications may appear on the client's medication list or could be
gathered from other systems. These medications are NOT restricted to those prescribed by your PBHCI program or clinic but could also include medications prescribed by
other physical health and behavioral health care providers (if you have access to this information). Do not limit your submission to psychiatric medications but attempt to
include all medications. Please report medications using NDC codes if available.
Medication
(NDC code)

Date Prescribed or Added to Medication List
(either mm/dd/yyyy or mmddyyyy is acceptable)

med_1

mmddyyyy

med_2

mmddyyyy

med_3

mmddyyyy

med_4

mmddyyyy

med_5

mmddyyyy

med_6

mmddyyyy

med_7

mmddyyyy

med_8

mmddyyyy

med_9

mmddyyyy

med_10

mmddyyyy

VI. Service Utilization Outside of Your Clinic/Agency Program
Report health care services used by the client outside of your clinic or PBHCI program.
Variable

Date (either mm/dd/yyyy or
mmddyyyy is acceptable)

inpt_1

mmddyyyy

inpt_2

mmddyyyy

inpt_3

mmddyyyy

inpt_4

mmddyyyy

ed_1

mmddyyyy

ed_2

mmddyyyy

ed_3

mmddyyyy

ed_4

mmddyyyy

pcout_1

mmddyyyy

pcout_2

mmddyyyy

pcout_3

mmddyyyy

pcout_4

mmddyyyy

Definition of Variables

Report dates of hospitalizations for any reason (mental health, substance use, physical health, or other). A hospitalization is when a client
is formally admitted into a hospital. Hospitalization does not include emergency room visits, partial hospitalization, day treatment, respite
care, or entry into a residential facility. We recognize that grantees will have access to different dates; some will be able to report
admission dates while others will only have access to discharge dates. We will accept either admission or discharge date. Please indicate in
your submission if the dates provided are admission or discharge dates.

Report dates of emergency department visits for any reason (mental health, substance use, physical health, or other). Some emergency
department visits may span more than one day. Please only report either the first or last day of the ED visit to avoid duplicate counting of
visits.

Report dates of physical health or primary care visits OUTSIDE of your clinic or PBHCI program. That is, primary care or specialty physical
health services that the client received elsewhere in the community from providers who are NOT formally or informally affiliated with
your PBHCI program. These visits may include referrals made by your PBHCI program and any other primary care services that were not a
result of a referral from your program. We recognize that some grantees have access to this information while others do not.

0 = No
pc_usc

1 = Yes
99 = Unknown

Report if the client had a primary care provider as his/her usual source of care BEFORE enrolling in PBHCI. Grantees are not expected to
access claims data to answer this question; data can be self-reported from client or captured at intake.