ATTACH 2_Evidence Based Telehealth Network Program Report (3)

OMB # 0906-XXXX-NEW. Expiration Date: (XX/XX/20XX)

Federal Office of Rural Health Policy (FORHP)
Office for the Advancement of Telehealth (OAT)
Evidence Based Tele-behavioral Health Network Program (EB THNP)
Substance Abuse Treatment Telehealth Network Grant Program (SAT TNGP)

RTRC Data Element Dictionary
The data element dictionary documents definitions, allowable values, sources for information, and
instructions for abstraction.

Instructions

Data elements that are collected at the PATIENT level ONCE at intake/baseline
NOTE that this first part of the document is specific to patient-level data elements that are
collected once, at intake, for each patient who received any behavioral health services as part of
the EB THNP/SAT TNGP or as part of a non-telehealth comparison sample for EB THNP/SAT
TNGP

Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:

Note for abstractions:

Source for definitions:
Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:
Note for abstractions:

Patient - 1
Treatment group
Indicates whether the patient is in the telehealth group or the non-telehealth
comparison group
Access
Check only one of the following. Options for response are:
□ Telehealth Treatment Group: Indicates that the patient was assigned to the
telehealth treatment group
□ Non-telehealth Treatment Group: Indicates that the patient was assigned to the
comparison group
This should indicate the patient’s assigned group. The patient is assigned to the
telehealth group if any telehealth services are planned. If the patient originally
intended to use telehealth services but then transferred out of those services and
received non-telehealth behavioral health services, the treatment group would
remain as originally assigned.
EB THNP Notice of Funding Opportunity (NOFO)
Patient - 2
Treatment site ID
An ID assigned to each treatment site
ID
Any alphanumeric character
 Check that the name of the site entered is consistent across measurement
periods.

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Source for definitions:
Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:
Note for abstractions:

Source for definitions:
Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:
Note for abstractions:

Source for definitions:
Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:

 The site will usually be the clinic/organization where the patient receives services
or where the provider/clinician providing telehealth is affiliated.
 This is not literally where the patient is located receiving telehealth services, but
instead is the clinic where the patient is affiliated for ID purposes. This serves as
a tracking mechanism for data management activities.
Rural Telehealth Research Center
Patient - 3
Patient ID
An ID assigned to each patient that is automatically converted to a non-linkable ID
when data are submitted to protect the patients’ confidentiality
ID
Any alphanumeric character
 This field should be used for internal purposes only to help grantees link data
elements for the same patient that might have been obtained from different
sources.
 The patient ID could be the patient’s full name or any other unique identifier.
 To protect the patients’ confidentiality, the patient ID should not be shared with
anyone outside the treatment network.
 To protect the patients’ confidentiality, a non-linkable case ID will be
automatically assigned to the record once it is submitted to RTRC. The patient ID
will never be uploaded or saved in the RTRC study database and is for your own
reference only.
Rural Telehealth Research Center
Patient - 4
Age
The patient's age at intake
Demographics
Any numeric character
 Patient age (in years) should be determined at intake.
 Do not round up. If the patient is X years and 11 months, enter X years.
 If the patient is over 90 years old, then enter 90.
US Census; CDC National Center for Health Statistics
Patient - 5
Sex
The patient's sex
Demographics
Check only one of the following. Options for response are:
□ Male
□ Female
□ Other: Can be used when/if patient is intersex or transitioning

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Note for abstractions:
Source for definitions:
Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:

Note for abstractions:

Source for definitions:

□ Unknown: Unable to determine the patient’s sex or not stated (e.g., not
documented, conflicting documentation, or patient unwilling to provide)
This can reflect the patient’s identified sex.
US Census; CDC National Center for Health Statistics
Patient - 6
Race
The patient's racial group
Demographics
Check only one of the following. Options for response are:
□ White: Patient’s race is White or the patient has origins in Europe, the Middle
East, or North Africa
□ Black or African American: Patient’s race is Black or African American
□ Asian: Patient’s race is Asian
□ Native Hawaiian or other Pacific Islander: Patient’s race is Native Hawaiian/Pacific
Islander
□ American Indian or Alaska Native: Patient’s race is American Indian/Alaska Native
□ Multiracial: Patient’s race is composed of or representing more than one racial
group
□ Unknown: Unable to determine the patient’s race or not stated (e.g., not
documented, conflicting documentation, or patient unwilling to provide)
 If documentation indicates the patient has more than one race (e.g., BlackWhite, Indian-White), select “Multiracial.”
 Although the terms “Hispanic” and “Latino” are actually descriptions of the
patient’s ethnicity, it is not uncommon to find them referenced as race. If the
patient’s race is documented only as Hispanic/Latino, select “Unknown.” If the
race is documented as mixed Hispanic/Latino with another race, use whatever
race is given (e.g., Black-Hispanic – select “Black”). Other terms for
Hispanic/Latino include Chicano, Cuban, H (for Hispanic), Latin American, Latina,
Mexican, Mexican-American, Puerto Rican, South or Central American, and
Spanish.
 Black or African American: A person having origins in any of the black racial
groups of Africa.
 American Indian or Alaska Native: A person having origins in any of the original
peoples of North and South America (including Central America) and who
maintains tribal affiliation or community attachment (e.g., any recognized tribal
entity in North and South America [including Central America], Native American).
 Asian: A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian subcontinent including, for example, Cambodia,
China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand,
and Vietnam.
 White: A person having origins in any of the original peoples of Europe, the
Middle East, or North Africa (e.g., Caucasian, Iranian, White).
 Native Hawaiian or Pacific Islander: A person having origins in any of the original
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
US Census; CDC National Center for Health Statistics

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Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:

Note for abstractions:

Source for definitions:
Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:

Patient - 7
Ethnicity
The patient’s ethnic group
Demographics
Check only one of the following. Options for response are:
□ Hispanic ethnicity or Latino/Latina: Patient is of Hispanic ethnicity or
Latino/Latina
□ Not Hispanic or Latino/Latina: Patient is not of Hispanic ethnicity or Latino/Latina
□ Unknown: Unable to determine the patient’s ethnicity or not stated (e.g., not
documented, conflicting documentation, or patient unwilling to provide)
Hispanic ethnicity and Latino/Latina signifies a person of Cuban, Mexican, Puerto
Rican, South or Central American, or other Spanish culture or origin, regardless of
race. The term “Spanish origin” can be used in addition to “Hispanic or Latino.”
Examples of documentation include:
 Black-Hispanic
 Chicano
 H
 Hispanic
 Latin American
 Latino/Latina
 Mexican-American
 Spanish
 White-Hispanic
US Census; CDC National Center for Health Statistics
Patient - 8
Patient’s insurance status
The type of insurance that the patient has at intake/baseline
Cost Savings/Effectiveness
Check only one of the following. Options for response are:
□ Medicare only: Select this option if Medicare is listed as the primary payment
source
□ Medicaid only: Select this option if Medicaid is listed as the primary payment
source
□ Dual Medicare/Medicaid: Select this option if both Medicare and Medicaid are
listed as payers
□ Private Insurance: Select this option if the primary payment source is worker’s
compensation or private insurance
□ Self-pay/uninsured: Select this option if the patient has no insurance coverage
and/or is paying out of pocket
□ Other, please specify:_____________________________________________
Select this option if the payment source does not coincide with one of the above
options (e.g. Veterans Administration, TRICARE/CHAMPUS)
□ Unknown: Unable to determine

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Note for abstractions:
Source for definitions:
Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:
Note for abstractions:

Source for definitions:
Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:
Note for abstractions:

Medicare includes Fee-For-Service (DRG or PPS) and Medicare Advantage
(HMO/Medicare+ Choice).
Rural Telehealth Research Center
Patient - 9
Patient travel miles to the initial planned place of behavioral health services
Miles from the patient’s location to where the patient plans to receive behavioral
health services
Cost Savings/Effectiveness
Any numeric character
 Information to answer this item should be determined at intake/baseline.
Locations may change in the course of treatment; use the location planned at the
time of intake only.
 The provider or staff completing the intake/baseline should make this
determination and does not need to ask the patient.
 Enter miles from the patient’s location to the patient’s proposed place of
behavioral health care.
 If the patient will be accessing telehealth from their home or work then enter
“0”.
 If the patient will be accessing telehealth from a clinic location then enter the
miles from the patient’s home to that clinic.
 If the patient will not be using telehealth then enter the miles from the patient’s
home to the location where they will be receiving the majority of their
behavioral health services.
 Use Google maps or similar program to determine the shortest travel miles by
car one way.
Modified PIMS
Patient - 10
Patient travel time to the initial planned place of behavioral health services
Time in hours/minutes from the patient’s location to where the patient plans to
receive behavioral health services
Cost Savings/Effectiveness
Any numeric character
 Information to answer this item should be determined at intake/baseline.
Locations may change in the course of treatment; use the location planned at the
time of intake only.
 The provider or staff completing the intake/baseline should make this
determination and does not need to ask the patient.
 Enter travel time from the patient’s location to the patient’s proposed place of
behavioral health care.
 If the patient will be accessing telehealth from their home or work then enter
“0”.
 If the patient will be accessing telehealth from a clinic location then enter the
travel time from the patient’s home to that clinic.

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Source for definitions:
Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:
Note for abstractions:

Source for definitions:
Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:
Note for abstractions:

Source for definitions:

 If the patient will not be using telehealth then enter the travel time from the
patient’s home to the location where they will be receiving the majority of their
behavioral health services.
 Use Google maps or similar program to determine the shortest travel time by car
one way.
Modified PIMS
Patient - 11
Patient travel miles to next likely source of behavioral health services
Miles from the patient’s location to the next likely source of behavioral health
services if the planned place of services was not available
Cost Savings/Effectiveness
Any numeric character
 Information to answer this item should be determined at intake/baseline.
 The provider or staff completing the intake/baseline should make this
determination and does not need to ask the patient. This determination should
be based on general knowledge of where other similar services are available. For
example, if the patient could not receive services at this clinic/location, how far
would they need to travel to receive behavioral health services addressing their
needs.
 Enter miles from the patient’s location to the patient’s likely source of behavioral
health care.
 Use Google maps or similar program to determine the shortest travel miles by
car one way.
Modified PIMS
Patient - 12
Patient travel time to next likely source of behavioral health services
Time in hours/minutes from the patient’s location to the next likely source of
behavioral health services if the planned place of services was not available
Cost Savings/Effectiveness
Any numeric character
 Information to answer this item should be determined at intake/baseline.
 The provider or staff completing the intake/baseline should make this
determination and does not need to ask the patient. This determination should
be based on general knowledge of where other similar services are available. For
example, if the patient could not receive services at this clinic/location, how long
would they need to travel to receive behavioral health services addressing their
needs.
 Enter travel time from the patient’s location to the patient’s likely source of
behavioral health care.
 Use Google maps or similar program to determine the shortest travel time by car
one way.
Modified PIMS

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Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:

Note for abstractions:

Source for definitions:

Instructions

Patient - 13
Patient likelihood of using next source of behavioral health services
The patient’s likelihood of using next source of care for type of service delivered
Cost Savings/Effectiveness
Check only one of the following. Options for response are:
□ NO likelihood of patient using next source of behavioral health services if the
planned place of services was unavailable
□ SOME likelihood of patient using next source of behavioral health services if the
planned place of services was unavailable
□ MODERATE likelihood of patient using next source of behavioral health services if
the planned place of services was unavailable
□ GREAT likelihood of patient using next source of behavioral health services if the
planned place of services was unavailable
□ Unknown: Unable to make any sort of determination of likelihood
 Information to answer this item should be determined at intake/baseline.
 The provider or staff completing the intake/baseline should make this
determination and does not need to ask the patient.
Modified PIMS

Data elements that are collected at INTAKE and on a defined REPEAT SCHEDULE
NOTE that this part of the document pertains to questions to be answered for each patient who
received services through the EB THNP/SAT TNGP and for the comparison sample. The
assessment instruments are to be administered (as appropriate to the patient) at
intake/baseline and repeatedly during treatment and at the end of the 3-month data collection
activity. Ideally, the assessment instruments would be administered monthly (at
baseline/intake, 1 month, 2 months, and 3 months). However, this may not be realistic in all
settings. The primary objective is to collect assessment instrument scores at the beginning,
during, and conclusion of the 3-month data collection activity and we ask grantees to do what
they can to collect this important data so that we have a good assessment of change in clinical
outcomes.

Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:
Note for abstractions:

Clinical Outcomes - 14
Assessment instrument administration timing
The number of weeks since the initiation of the treatment to the time when the
assessment instrument(s) were re-administered
Clinical Outcomes
Any numeric character
 The initial administration of the assessment instruments would be time zero and
“0” should be entered.
 The first re-administration would ideally occur 3 – 5 weeks after the treatment is
initiated.
 The second re-administration would ideally occur 7 – 9 weeks after the
treatment is initiated.

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Source for definitions:
Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:
Note for abstractions:
Source for definitions:

Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:

 The third re-administration would ideally occur 11 – 13 weeks after the
treatment is initiated.
 Enter the actual number of weeks since the initiation of the treatment even if it
differs from the ideal timing.
 Round the number of weeks to a whole number. For example, if an assessment is
administered three weeks and four days since treatment initiation, enter “4”
weeks.
Rural Telehealth Research Center
Clinical Outcomes - 15
PROMIS Global Health – Mental Health score (component)
Use the Patient-Reported Outcomes Measurement Information System (PROMIS)
Global Health (Mental Health component) to assess patient functioning
Clinical Outcomes
Any numeric character
Total scale score should be between 4 and 20.
Hays RD, et al. Development of Physical and Mental Health Summary Scores from
the Patient-Reported Outcomes Measurement Information System (PROMIS) Global
Items. Qual Life Res. 2009;18(7):873-880.
Clinical Outcomes - 16
PROMIS Global Health – Physical Health score (component)
Use the Patient-Reported Outcomes Measurement Information System (PROMIS)
Global Health (Physical Health component) to assess patient functioning
Clinical Outcomes
Any numeric character

Note for abstractions:
Source for definitions:

Total scale score should be between 4 and 20.
Hays RD, et al. Development of Physical and Mental Health Summary Scores from
the Patient-Reported Outcomes Measurement Information System (PROMIS) Global
Items. Qual Life Res. 2009;18(7):873-880.

Data element number:
Variable name:
Variable definition:

Clinical Outcomes - 17
PROMIS Global Health score (total)
Use the Patient-Reported Outcomes Measurement Information System (PROMIS)
Global Health to assess patient functioning
Clinical Outcomes
Any numeric character

Domain:
Valid (allowable) values:
Note for abstractions:
Source for definitions:

Total scale score should be between 10 and 50.
Hays RD, et al. Development of Physical and Mental Health Summary Scores from
the Patient-Reported Outcomes Measurement Information System (PROMIS) Global
Items. Qual Life Res. 2009;18(7):873-880.

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Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:
Note for abstractions:

Source for definitions:

Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:
Note for abstractions:

Source for definitions:

Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:
Note for abstractions:

Clinical Outcomes - 18
PHQ-9 depression symptoms score
Use the Patient Health Questionnaire – 9 (PHQ-9) to assess depression symptoms
Clinical Outcomes
Any numeric character or “N/A” if not applicable to this patient
 Patients who received behavioral health services during the measurement period
and whose primary complaint is depression or who have a first-listed or secondlisted ICD-10 code indicative of depression should be administered the PHQ-9 at
each repeat assessment.
 Total scale score should be between 0 and 27.
 Enter “N/A” if the patient did not have a primary complaint of depression or did
not have a first-listed or second-listed ICD-10 code indicative of depression.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a brief
depression severity measure. Journal of General Internal Medicine, 16(9), 606-13.
Clinical Outcomes - 19
GAD-7 generalized anxiety symptoms score
Use the Generalized Anxiety Disorder Scale – 7 (GAD-7) to assess anxiety symptoms
Clinical Outcomes
Any numeric character or “N/A” if not applicable to this patient
 Patients who received behavioral health services during the measurement period
and whose primary complaint is anxiety or who have a first-listed or second-listed
ICD-10 code indicative of anxiety should be administered the GAD-7 at each
repeat assessment.
 Total scale score should be between 0 and 21.
 Enter “N/A” if the patient did not have a primary complaint of anxiety or did not
have a first-listed or second-listed ICD-10 code indicative of anxiety.
Spitzer, R. L., Kroenke, K., Williams, J. B., & Lowe, B. (2006). A brief measure for
assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine,
166(10), 1092-1097. doi:10.1001/archinte.166.10.1092
Clinical Outcomes - 20
DUDIT-C substance use severity score
Use the Drug Use Disorders Identification Test - Consumption (DUDIT-C) to assess
substance use severity
Clinical Outcomes
Any numeric character or “N/A” if not applicable to this patient
 Patients who received behavioral health services during the measurement period
and whose primary complaint is substance use or who have a first-listed or
second-listed ICD-10 code indicative of substance use should be administered the
DUDIT-C at each repeat assessment.
 Total scale score should be between 0 and 16.
 Enter “N/A” if the patient did not have a primary complaint of substance use or
did not have a first-listed or second-listed ICD-10 code indicative of substance use.

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Source for definitions:

Berman AH, Bergman H, Palmstierna T, Schlyter F. DUDIT Manual (the Drug Use
Disorders Identification Test). Stockholm, Sweden: Karolinska Institutet, Department
of Clinical Neuroscience; March, 2003. Version 1.0.
Berman AH, et al. Evaluation of the Drug Use Disorders Identification Test (DUDIT) in
Criminal Justice and Detoxification Settings and in a Swedish Population Sample. Eur
Addict Res. 2005;11(1):22-31.

Instructions

Data elements that are collected at EACH ENCOUNTER
NOTE that this part of the document pertains to questions to be answered for each patient who
received services through the EB THNP/SAT TNGP and for the comparison sample at each
encounter. Only those encounters that are delivered as part of the EB THNP/SAT TNGP during
the first three (3) months of treatment should be entered.

Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:

Note for abstractions:
Source for definitions:
Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:
Note for abstractions:

Source for definitions:
Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:

Encounter - 21
Treatment type
Indicate whether encounter was planned to be by telehealth services or by nontelehealth services
Access
Check only one of the following. Options for response are:
□ Encounter planned to be by telehealth services
□ Encounter planned to be by non-telehealth services
Patients in the Telehealth Treatment Group may, at times, be seen in a face-to-face
encounter.
Rural Telehealth Research Center
Encounter - 22
Timing of encounter
Number of days since first treatment encounter
Access
Any numeric character
First treatment encounter is the first time the patient has a provider encounter.
Note that administration of assessment instruments (e.g. PROMIS, PHQ-9) may take
place prior to first treatment encounter.
Rural Telehealth Research Center
Encounter - 23
Therapy scheduling success
Whether or not scheduled session was completed
Access
Check only one of the following. Options for response are:
□ Successful: Scheduled encounter was successfully completed

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Note for abstractions:

Source for definitions:
Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:

Note for abstractions:

Source for definitions:
Data element number:
Variable name:
Variable definition:

Domain:

□ Unsuccessful due to Patient: Scheduled encounter was NOT successfully
completed because the PATIENT failed to appear or refused service
□ Unsuccessful due to Provider: Scheduled encounter was NOT successfully
completed because the PROVIDER failed to appear
□ Unsuccessful due to Technology: Scheduled encounter was NOT successfully
completed because TECHNOLOGY failed
□ Unknown: Scheduled encounter where it is impossible to determine from EMR,
log, or patient visit record
□ Other, please specify:__________________________________________
 Successful administration means that both the patient and provider attended the
behavioral health service encounter as scheduled.
 If either the patient or the provider failed to attend the behavioral health service
encounter as scheduled then check the appropriate unsuccessful box.
 If both the patient and provider tried to have a telehealth encounter but the
technology failed and prevented the telehealth encounter from occurring then
check the box indicating that the session was unsuccessful due to technology.
 If unable to determine whether the behavioral health service encounter was
completed as scheduled, select “Unknown.”
Modified PIMS; Rural Telehealth Research Center
Encounter - 24
Provider type
Type of provider/clinician seen for behavioral health services during this encounter
Access
Check only one of the following. Options for response are:
□ Psychiatrist or other Physician (MD or DO)
□ Psychiatric or Mental Health Advanced Practice Provider (NP or PA)
□ Clinical Psychologist (PhD or PsyD)
□ Nurse Psychotherapist (MA or MS trained RN)
□ Clinical Social Worker (MSW or LCSW)
□ Other, please specify:__________________________________________
□ Unknown: Unable to determine from EMR, log, or patient visit record
 The word “provider” is meant to include any type of professional or lay person
acting as a therapist or clinician for a behavioral health encounter.
 If more than one clinician was involved in an encounter then check the box
indicating the most essential clinician.
Rural Telehealth Research Center
Encounter - 25
Patient’s behavioral health diagnoses
The International Classification of Diseases, Tenth Revision (ICD-10) code(s)
associated with the diagnosis established to be chiefly responsible for the
behavioral health services
Clinical Outcomes

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Valid (allowable) values:

Note for abstractions:

Source for definitions:
Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:

Note for abstractions:
Source for definitions:
Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:

_______ Any valid ICD-10 code listed as the primary diagnosis in the form of
XXXX.XX
_______ Any valid ICD-10 code listed as the secondary diagnosis in the form of
XXXX.XX or “N/A” if no secondary diagnosis listed ICD-10 is available
 Refer to ICD-10 code table.
 The primary ICD-10 code is required.
 If no secondary ICD-10 code is listed, then enter N/A.
Modified PIMS
Encounter - 26
Treatment service type
CPT code for each encounter
Access & Cost Savings/Effectiveness
Check the CPT code assigned to this encounter. Options for response are:
□ 90791 Psychiatric diagnostic evaluation without medical services (intake
interview)
□ 90792 Psychiatric diagnostic interview (for prescribers / medical services)
□ 90832 Individual psychotherapy, 30 minutes (16-37 minutes)
□ 90834 Individual psychotherapy, 45 minutes (38-52 minutes)
□ 90837 Individual psychotherapy, 60 minutes (53 minutes and over)
□ 90839 Psychotherapy for crisis, 60 minutes (30-74 minutes)
□ 90853 Group psychotherapy, 60 minutes
□ 96150 Health & Behavioral Assessment – Initial (each 15 mins)
□ 96151 Health & Behavioral Reassessment (each 15 mins)
□ 96152 Health & Behavior Intervention – Individual (each 15 mins)
□ 99212 Evaluation and management, focused history
□ 99213 Evaluation and management, expanded history
□ 99214 Evaluation and management, detailed history
□ 99215 Evaluation and management, comprehensive history
□ Other, please specify:__________________________________________
□ Unknown: Unable to determine from EMR, log, or patient visit record
This data element must be completed for all encounters. It will be used to estimate
cost reimbursements.
Rural Telehealth Research Center
Encounter - 27
Disposition recommendation
Indicates the provider’s recommended disposition for the patient at the end of the
encounter
Clinical Outcomes
Check only one of the following. Options for response are:
□ Treatment completed
□ Continue ongoing sessions at about the same frequency
□ Continue treatment on a more frequent schedule
□ Continue treatment on a reduced schedule

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OMB # 0906-XXXX-NEW. Expiration Date: (XX/XX/20XX)

Note for abstractions:

Source for definitions:
Data element number:
Variable name:
Variable definition:
Domain:
Valid (allowable) values:

Note for abstractions:

Source for definitions:

□ Transfer to another behavioral health provider
□ Admit to inpatient/rehab facility or unit
□ Discharge home
□ Other, please specify _____________________________________________
□ Unknown: Unable to determine from EMR, log, or patient visit record
The disposition determination should reflect the provider’s recommendation at the
conclusion of the encounter. It does not reflect what action was later taken by the
patient.
Rural Telehealth Research Center
Encounter - 28
Treatment billing
Indicates whether or not the behavioral health services encounter was billed to
insurance
Cost Savings/Effectiveness
Check only one response option. Options for response are:
□ This encounter was billed to insurance
□ This encounter was part of a global fee or bundle payment model □ This
encounter was NOT billed to insurance and not part of a global fee or bundle
payment model
□ Unknown: Unable to determine from EMR, log, or patient visit record
 Insurance includes Medicare, Medicare, Private Insurance, VA, etc.
 If patient is covered under a capitated or similar program where encounters are
not billed then “This encounter was part of a global fee or bundle payment
model” should be checked.
 If patient does not have insurance or is Self-Pay then the response options “This
encounter was NOT billed to insurance” should be checked.
Rural Telehealth Research Center

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. The OMB control number for
this project is 0906-XXXX-NEW. Public reporting burden for this collection of information is estimated to average
14 hours per response, including the time for reviewing instructions, searching existing data sources, and
completing and reviewing the collection of information. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports
Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857.

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