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CVR Instruction Manual Region X, Title X Family Planning

Contents

1. 06 Substance Abuse 18 Relationship Safety 07 Pregnancy Options 19 BSE 08 Preconception 20 TSE 09 STD HIV Prevention 10 HIV Pre amp Post RED NOTES DESCRIPTION CHANGES OR ADDITIONS Contraceptive Methods Attachment E 01 Female Sterilization 13 Abstinence Pills 14 Male Sterilization 15 IUS 04 Diaphragm Cervical Cap 16 Hormone Injection 3 Months 06 Male Condoms 17 Hormone Patch 18 Vaginal Ring 19 Female Condoms 09 Other Female Method 10 None 20 Withdrawal 21 Contraceptive Sponge 11 Hormone Implant Reason for No Method Attachment F 1 Planned Pregnancy 8 Unplanned Pregnancy 3 Seeking Pregnancy 6 Not Sexually Active 7 Other Female Only medical Services Attachment G 09 Bimanual Speculum Exam 11 No Longer Female Only Services 31 Serum Pregnancy Test 32 Negative Pregnancy Test 12 No Longer Female Only Services 33 Positive Pregnancy Test 17 Diaphragm Cervical Cap Fit 38 Hormone Implant In 19 IUD IUS Insertion 39 Hormone Implant Out 21 Post Pregnancy Exam 40 Hormone Injection 25 Pap Test Conventional 46 EC Future Need 26 Pap Test Liquid Based 48 EC Immediate Need 27 Colposcopy 22 IUD IUS Removal 31 Exhibit 4 Region X 3rd Party Vendors CVR F
2. before block insert the code of the primary or most effective method even if more than one method is used In the after box insert the corresponding number of the primary or most effective method at the end of the visit even if more than one method will be used Skip 15B if a method was filled out in both the before and after boxes If the client receives both an interim and primary method code the primary method only If the client does not receive her his primary method code the interim method to be used 15B If no contraceptive method is continued or initiated at the end of this visit enter code 10 for none in 15A and the most important reason for this decision in 15B This reply directly affects table AL 7 Pregnancies Averted For infertility clients code the contraceptive method as None in 15A Even if a method is being used as treatment the purpose of this method is not to prevent pregnancy but to create the condition for fertility The current list of contraceptive methods follows 01 Female Sterilization 02 Oral Contraceptives 03 IUD 04 Diaphragm Cap 11 Hormone Implant 15 IUS 16 Hormonal Injection 3 month 17 Hormonal Patch 18 Vaginal Ring 09 Other Method 19 Female Condom 06 Male Condom 07 Spermicide 08 NFP FAM 13 Abstinence 14 Male Sterilization 20 Withdrawal 21 Contraceptive Sponge 10 None 21 2 16 Referral Information
3. 2009 COVE vi ia ests toncntaninnakinniie la manasonbaessa te iediebasaneenuiacs 28 Third party file specifications cccccecssccscccescccescesecs 29 Third party file attachments ccseccsscccscccsccccsccesecs 30 Third party field values sccssccscccsccccscccsccccsscescceees 32 Processing Calendar sscissiscscssecasdssessssacssesncevstvenateessesses 33 Letter on Region X and HIPAA cccccscccssccscccssccesees 35 Ahlers website application cccscccssccssccccscccscceees 38 Grantee Contact List ssiccicsacacdccasccssersscscesvessandieacnasiades ese 39 1 0 Introduction and Definitions What are Title X and Region X In 1970 Congress created the Family Planning Services and Population Research Act which added the Title X Population Research and Voluntary Family Programs to the Public Health Service Act Title X is a federal grant program administered by the Office of Population Affairs OPA under the Department of Health and Human Services This law provides funding for comprehensive family planning services and information to allow all individuals to exercise choice in determining the number and spacing of their children Recipients of Title X grant dollars agree to abide by Title X requirements Title X is probably one of several funding sources your clinic project site uses In addition to contraceptive services Title X clinics provide limited physical exams for women and men screening for brea
4. Oct 15 Oct 25 Oct 30 Oct 30 Nov 15 Nov 25 Dec 8 Dec 15 Dec 25 Dec 30 Jan 7 Jan 15 Jan 25 Jan 30 Jan 30 Feb 14 Quarterly reports for April Jun produced by Ahlers FPAR Semi annual tables produced by Ahlers June processing reports completed by Ahlers Region X Fiscal Year Annual tables produced by Ahlers Deadline for arrival of July CVRs at Ahlers July rejected CVRs returned to projects sites July processing reports completed by Ahlers Deadline for arrival of August CVRs at Ahlers August rejected CVRs returned to projects sites August processing reports completed by Ahlers Deadline for arrival of September CVRs at Ahlers September rejected CVRs returned to projects sites September processing reports completed by Ahlers Quarterly reports for July September produced by Ahlers Deadline for arrival of October CVRs at Ahlers October rejected CVRs returned to projects sites October processing reports completed by Ahlers Deadline for arrival of November CVRs at Ahlers November rejected CVRs returned to projects sites FPAR Annual tables produced by Ahlers Nov Nov November processing reports completed by Ahlers Deadline for arrival of December CVRs at Ahlers December rejected CVRs returned to projects sites December processing reports completed by Ahlers Quarterly reports for Oct Dec produced by Ahlers Region X Calendar Year Annual Tables produced by Ahlers 34 Exhibit 6 To Family Planning Providers From Rich Ahl
5. is a subject that the computer uses to detect errors A CVR for a revisit must have the same date of birth as the CVRs for the client s previous visits to the service site If the revisit date of birth does not match the first date of birth the CVR will be rejected by the system This is the most common type of rejection in the system Some clients do change their birth dates If is recommended that the first date entered be used consistently 2 5 Gender No 5 Determination of gender is made by observation or from medical records Check the appropriate box 2 6 Ethnicity No 6 One of the two boxes must be checked Hispanic or Latino or Not Hispanic or Latino If the answer to this is not indicated on the client s medical record you may ask that they fill out the section for ethnicity You can ask Do you consider yourself Hispanic or Non Hispanic If the client has questions about ethnicity you may tell them that in addition to race identification information on this category is now needed too It is important not to make assumptions about someone s ethnicity in this category Note Hispanic Origin or descent includes 1 Mexican American Mexicana o Americana o 2 Puerto Rican Puerto Riquena o 3 Cuban Cubana o 4 Central or South American Centro o Sudamericana o 5 Other Spanish Speaking Otra Categoria Espanol Race No 6A Check all that apply If not indicated on the clients medical record you may a
6. sent in X12N837 format By filing an extension request with HHS an automatic extension to October 2003 was granted Ahlers hopefully along with each of you filed for the extension As a Clearinghouse Ahlers is entitled to receive non standard records until the regulations are changed And as mentioned earlier we are a Clearinghouse in Oregon Illinois Texas and New York You may continue to send us visit data in the current format If you use Third Party software we are required to accept X12N837 records if asked to do so We must be prepared to begin testing in April 2003 Our hope is that you will continue to use the current format Ahlers must file X12N837 records with the health plans payor if those records are submitted electronically Currently only Oregon Medicaid Illinois Medicaid New York Medicaid and all Texas claims are filed electronically We will begin testing with those organizations in April 2003 with completion by October 2003 Those of you who use our Insurance Billing System file your claims on paper not subject to X12N837 or through PerSe also a Clearinghouse PerSe can continue to accept non standard records and will file them with payors in X12N837 format in October 2003 The X12N837 claim record contains some fields not currently captured by Ahlers Insurance Billing System You will receive an enhancement to add those fields prior to October What About Standard CPT and ICD9 Codes Standard CPT coding and
7. ADDITIONS Medical Services Attachment C 02 Blood Pressure 28 Gonorrhea Culture 03 HgtlWgt 04 Thyroid Exam 29 Chlamydia Test 30 Wet Mount 05 Hear LunQ Aus 31 Serum Pregnancy Test 06 Breast Exam 32 Negative Pregnancy Test 07 Abdominal Exam 33 Positive Pregnancy Test 08 Extremities 34 Immunization 09 Bimanual Speculum Exam 11 Vaginitis Urethritis Eval Dx 35 Infertility Screening 36 Other Lab or Exam 12 Vaginitis Urethritis Eval RX 37 No Lab or Exam 13 Chlamydia Treatment 38 Hormone Implant In 14 Chlamydia Presumptive Rx 39 Hormone Implant Out 15 Wart Treatment 40 Hormonal Injection 16 Herpes 17 Diaphragm Cervical Cap Fit 42 Male Genitalia Exam 43 HIV Test Standard 19 IUD IUS Insert 44 HIV Test Rapid 20 Sterilization 21 Post Pregnancy Exam 46 EC Future Need 47 VDRL RPR 22 IUD IUS Removal 48 EC Immediate Need 23 HGB HCT 24 Urine Dip Strip Urinalysis 49 Colo Rectal Cancer Screen 50 HPV Test 25 Pap Conventional 26 Pap Liquid Based 27 Colposcopy 30 RED NOTES DESCRIPTION CHANGES OR ADDITIONS 01 Contraceptive 12 Nutrition 02 F A M 13 Abstinence 03 Sterilization 15 Crisis 04 Infertility 16 Abnormal Pap 05 Tobacco 17 Encourage Family Involvement
8. LIMITED ENGLISH PROFICIENCY This table reports the total number of users who require an interpreter while being seen in the clinic FPAR TABLE 7 PRIMARY CONTRACEPTIVE METHOD AND AGE FOR FEMALE USERS This table provides information on the contraceptive method adopted or continued by female users at the end of their last visit The method does not have to have been provided by the agency and it may have been dispensed performed during an earlier visit In addition to the Method the client age groups are shown FPAR TABLE 8 PRIMARY CONTRACEPTIVE METHOD AND AGE FOR MALE USERS Records the same information for male contraceptive clients 23 FPAR TABLE 9 CERVICAL CANCER SCREENING ACTIVITIES Only the first two lines of this report will be produced by Ahlers These lines describe 1 unduplicated users who received a Pap test and 2 total Pap tests performed The specific Pap results are to be kept by the clinic Ahlers Lab Results software will prove useful in this collection FPAR TABLE 10 BREAST HEALTH SCREENING AND REFERRALS All clients who received a breast exam are reported on line one Those who are referred for further evaluation are reported on line two FPAR TABLE 11 USERS TESTED FOR CHLAMYDIA BY AGE AND SEX All clients who received a Chlamydia test during the year and reported by sex and by several age categories FPAR TABLE 12 STD TESTING INFORMATION BY SEX This table provides information
9. Title X Client Data are the same In Region X clinics and projects use a variety of methods and software to collect this information Some use the clinic software distributed by the regional data processor Ahlers and Associates some use the paper CVRs and others use a variety of clinic based billing and or client information systems 3 party For those who use the paper CVR the sections in Section 2 are easy to follow For those of you using computerized systems the terms in Section 2 are included in your computer systems although they may appear in a different order Where does the CVR data go In the Region X system monthly quarterly yearly annual and yearly fiscal July June data are submitted either via mail for paper CVRs or electronically through the use of an FTP File Transfer Protocol website The data are submitted to Ahlers and Associates in Waco Texas where they are scanned for errors tallied and parsed into usable information in the region wide tables also know as data reports Ahlers software Users We use Ahlers software WINCVR Is it the same as the paper CVR Yes Ahlers and Associates have built their WINCVR system around a modular client Information System that is oriented toward public health and family planning The region wide CVR components are included in this system For programmers a copy of the file transfer layout the layout for transmitting your data over the internet for WINCV
10. Title X reporting just don t seem to go together Blood pressure bimanual pelvic exams etc do not have specific CPT codes but are likely provided in certain Office Visit CPT codes Ahlers is awaiting direction from the Medicaid paying organizations in our billing states and that direction has not been forthcoming at this writing As soon as we receive information from those organizations we will be available to consult with the affected states on how to comply by the deadline Those agencies using our Insurance Billing module have the flexibility to use whatever CPT and ICD9 codes they desire Conclusion This letter represents our best interpretation of HIPAA We hope it represents where we each are as we seek to comply with the law If you have questions or concerns please let me know at 800 888 1836 ext 113 or joe ahlerssoftware com 37 Exhibit 7 Ahlers Web Page Security Application Management reports prepared by Ahlers are available at www ahlerssoftware com The confidentiality of the reports necessitates the use of a User ID and Password Please keep your User ID and Password confidential If other staff members in your organization are authorized to view the reports have them apply for a personal User ID and Password Please complete the attached application and fax it to 254 755 0267 Attn Debby or Gracie Ahlers will confirm your eligibility with the Region State or Agency and assign your Password Your Password will
11. be communicated with you by phone from the individual who approved your application Password Application Please Print User ID limit 9 letter and or numbers Name Title Address City State Phone Email address Authorization for Region all inclusive Region State Project Clinic reports _ State includes all Projects and Clinics in State Project includes all Clinics within Project __ s Clinic includes only Clinic reports List all Clinic Numbers for which your are seeking authorization For Use By Ahlers Password Security Status Application Status 38 Exhibit 8 CONTACTS Names in red denote primary grantee contact Regional Office Oregon Dept of Human Svcs Marjie Witman Regional Program Consultant 206 615 2501 marjie witman hhs gov Lou Glass Regional Nurse Consultant 206 615 2776 louis glass hhs gov Mailing Address U S Public Health Service Office of Family Planning MS 29 2201 Sixth Ave Ste 800 Seattle WA 98121 2500 FAX 206 615 2481 Rian Frachele Reproductive Health Section Manager 971 673 0364 rian frachele state or us Karol Almroth FP Operations Coordinator 971 673 0357 karol L almroth state or us Carol Elliott Nursing Consultant 971 673 0362 carol j elliott state or us Cheryl Connell Nursing Consultant 541 265 2248 ext 443 cheryl s connell state or us Mailing Address Oregon Dept Huma
12. changes Updates to the program are made based on required changes directed by OPA and on feedback from grantees and clinic staff Internal and external expertise from Information System professionals are consulted before final changes are made What is a CVR A CVR or Clinic Visit Record is a data collection tool designed to record the required information about a Family Planning client who is making a Family Planning Visit When and whom do I record a CVR A CVR is generated for a family planning client on a family planning visit in a clinic that receives Title X funding and follows Title X Guidelines The definitions for these follow Family Planning Client A family planning client is an individual of reproductive age 10 through 55 who receives medical and or counseling services related to contraception sterilization infertility treatment or related care and for whom a medical record is established There are no residential citizenship requirements no one may be refused services based on an inability to pay Family Planning Visit A family planning visit is a visit where medical and or counseling services are provided in conjunction with contraception sterilization infertility treatment or related care and the services are recorded in the medical record This must be a face to face contact In some clinics the CVR is a paper form to be filled out when the two previous definitions have been met In other clinics the CVR may simp
13. family that is ner the number supported by this income NUMBER 11 PREGNANCY HISTORY Females Only a How many times have you been pregnant 12 PURPOSE OF VISIT _ 1 Initial Medical Exam 2 Annual Medical Exam L13 Other Medical _ 4 Counseling Only 5 Pregnancy Test Visit 13A MEDICAL SERVICES Check all Applicable C101 Procedures 2 through 9 J 23 Hgb Het and check appropriate C 24 Urine Dip Strip Urinalysis lab services 25 Pap Test Conventional Exam amp Lab Services 26 Pap Test Liquid Based J 02 Blood Pressure C127 Colposcopy 03 Height Weight C134 Immunization L104 Thyroid Exam 42 Male Genitalia Exam L105 Heart Lung Auscultation C 49 Colo Rectal Cancer 106 Breast Exam Screening J 36 Other Lab or Exam 37 No Lab or Exam 107 Abdominal Exam C08 Extremities 109 Bimanual Speculum Pelvic Exam AHLERS amp ASSOCIATES WACO TEXAS 13B 14B PROVIDER OF MEDICAL SERVICES COUNSELING EDUCATION SERVICES Mark all that Apply C 1 Physicians _ 2 Physician Assistants Nurse Practitioners Certified Nurse Midwives 1 3 RNs LPNs M 4 Other service providers health educators social workers clinic aides and lab technicians 15A PRIMARY CONTRACEPTIVE METHOD Complete before and after blocks 09 Other Method 01 Female Sterilization 19 Female Condom 02 Oral Contraceptives 06 Male Condom 03 IUD 07 Spermicide 04 Diaphrag
14. to whom and by who their health information was given Is Ahlers Compliant With The Privacy Provisions Ahlers has been receiving transmissions from a number of clients on the FTP server for several months We will provide you with this path prior to the April deadline The CVR System modifications will be complete and you will receive an update prior to April to satisfy the Unique User ID Time Out Feature and Disclosure Log requirement The Ahlers DOS software CVR Plus cannot be updated for the Privacy features Contact Gary Garcia 800 888 1836 ext 133 if you wish to upgrade to Windows The upgrade fee for the CVR is 700 and the remaining modules vary in cost Gary can provide you with a quote 36 What About Security No deadline has been established at this writing but the proposed regulations are likely to be approved as written Ahlers has only one duty in Security That is to password protect the Ahlers software so that an unauthorized person cannot remove the software and files to a different machine install a copy of our programming language and then view the data That enhancement will be added before April along with the Privacy provisions mentioned previously The larger burden of Security rests with your staff in doing regular backups using anti virus software etc What About Standard Transaction Sets HIPAA required that in October 2002 that health care information relating to reimbursement claims be
15. trained personnel concerning sexually transmitted disease including HIV prevention and education 19 10 HIV Pre amp Post Counseling Education Consultation and information provided to a client by trained personnel concerning HIV during the pre test or post test visit 12 Nutrition Counseling Education Consultation information provided to a client regarding nutrition that promotes health and prevents disease 13 Abstinence Counseling Education Consultation information regarding abstinence from sex not having intercourse and discussion of positive outcomes of this decision such as protection from pregnancy and sexually transmitted disease 15 Crisis Counseling Education Consultation education provided to a client by trained personnel regarding a crisis identified by the client 16 Abnormal Pap Counseling Education Consultation education between a client and trained personnel regarding an abnormal pap result 17 Encourage Parental Family Involvement Counseling Education Consultation education provided to a client by trained personnel regarding the encouragement of family participation in the decision of minors to seek family planning services 18 Relationship Safety Counseling Education Consultation education provided to a client by trained personnel on how to resist attempts from others to engage in unwanted sexual activities This includes teaching refusal skills to prevent coercion Relationship safety may also include
16. 43 4794 morissera muni org Michelle Marshall Asst RH Program Mgr 907 343 4789 marshallml muni org Mailing Address Municipality of Anchorage P O Box 196650 825 L St Ste 102 Anchorage AK 99519 6650 FAX 907 343 4633 40 Planned Parenthood of the Great Planned Parenthood Columbia Willamette NorthWest AK Christine Charbonneau Kathleen Altman CEO Vice President Patient Services 206 328 7734 Christine charbonneau ppgnw org Clover Simon Federal Program Administrator 907 770 9705 clover simon ppgnw org Anita Owings Area Service Manager AK amp ID 208 376 2277 x10 office 208 484 7019 mobile anita owings ppgnw org Mailing Address 4001 Lake Otis Pkwy Anchorage AK 99508 FAX 907 565 7529 503 775 4931 ext 2202 Kathleen altman ppcw org David Grenberg President CEO 503 775 4931 x2201 David greenberg ppew org Mailing Address 3231 SE 50th Ave Portland OR 97206 FAX 503 788 7285 Planned Parenthood of the Great Center for Health Training NorthWest ID Christine Charbonneau David Fine CEO Vice President 206 328 7734 Christine charbonneau ppgnw org Clover Simon Federal Program Administrator 907 770 9705 clover simon ppgnw org Anita Owings Area Service Manager AK amp ID 208 376 2277 x10 office 208 484 7019 mobile anita owings ppgnw org PPGNW 1109 Main St 500 Boise ID 83702 FAX 208 376 9401 dfine jba
17. CVR Instruction Manual Region X Title X Family Planning Information System Revised June 2011 For further questions concerning the use of this manual or on site training contact David Fine PhD Region X Family Planning Information System Center for Health Training 206 447 9538 Email dfine jba cht com Table of Contents 1 Introduction and Definitions Title X and Region X ss vasscdvnsstccsaveccsessasseisdcacsdccssvsccvcsens 2 The Family Planning Information System essee0 2 The Clinic Visit Record CVR eesssessessosseoseesosssoseesoeeo 3 Who to CV iene iscen cascnvessedaiwnsnss sadnguncasseecensiesinssacianess 3 Data TOW viicassecseecsusevsnatsadsnaavirkenssdcaciesendavenaegauenbidacesens 4 Ahlers software versus a paper CVR cccccescccsscesccecees 4 Third party software collecting CVR data ccsecessceees 4 Torun a test DAC fc sicsidccssnnainascsetassasngaeasaswesdsenecsasecenes 5 To confirm a transmission eseeseessosoossssssssssessssseseseso 5 To resubmit a rejected CVR cccccscsccssccscsccssccccccsecceccs 5 HIPAA complianCy ssessesssssessescsescooosososssssssseseeseeeeo 5 Ahlers website ssssssesssssosssssserrsasessiseess snenie seeseandacee snes 6 2 How to collect Region X Title X CVR data Services Site Number sssesssssesesssososessssesessessooosesesseee 7 Client NUMIDER sisiccaniwics seaswcieinedsciewnsednnisarpecteteraecewmcciwets 7 Date OF Vi
18. No 16 Referral Information is used to indicate whether the client was referred to another agency clinician or another program in a multi service project Check all that apply to the client for the current visit All referral information must be documented in the client medical record 22 3 0 National Title X Data Reporting Family Planning Annual Report FPAR TABLES The FPAR Family Planning Annual Report tables are produced to meet the Title X reporting requirements All tables are produced annually The FPAR table descriptions below are numbered to correspond with the table numbers in the FPAR FPAR TABLE 1 USERS BY AGE AND SEX This table reports users by age group and sex It includes individuals receiving at least one face to face family planning encounter during the reporting period FPAR TABLE 2 amp 3 USERS BY RACE AND ETHNICITY Table 2 reports females and Table 3 reports males In both tables the Race is reported in the left axis and Ethnicity is reported on the top axis FPAR TABLE 4 NUMBER OF USERS BY INCOME LEVEL This table shows unduplicated count of users by poverty level FPAR TABLE 5 USERS BY INSURANCE COVERAGE STATUS This table reports the principal insurance status of all users Public health insurance is reported on the top line and Private health insurance is reported in total as well as by family planning coverage Uninsured and Unknown status is also reported FPAR TABLE 6 USERS WITH
19. R users is provided in this manual Third party software users We use another client billing software How will this capture the CVR client information for Title X Most of the components of the CVR are common among client registration systems super bills and most standard billing software There may be a few items that the region collects that are not included in your system such as data on referrals counseling etc To facilitate programmers in capturing and transmitting the required data a file format for third party users those clinics that use software other than Ahler is provided in this manual See exhibits Your IT person can contact Debby Pustejovsky at Ahlers for further assistance How do we know our data is really reaching Ahlers Can we run a test batch Anytime the CVR is upgraded or changed or your site changes Information Systems it is a good idea to send a monitored test batch of data to the FTP site through an electronic transmission via the Internet It is also a good idea to do this far in advance of the 15 calendar day of each month which is the cut off for monthly data An employee from Ahlers can walk you through the process they will also help you look for data anomalies and incomplete files Please contact Debby Pustejovsky at Debby ahlerssoftware com 1 800 888 1836 ext 132 or Sam Odajima 1 800 888 1836 ext 124 or Sam ahlerssoftware com E mail Confirmations Sites are also aske
20. R 4 e Male physical examination e Contraceptive method change related to method complaints e g UD removal poor diaphragm fit because of complaints e Contraceptive method complaints e g pelvic exam because of abdominal pain excessive bleeding fatigue etc 14 e Positive or borderline lab test follow up e g repeat Pap smear monitoring of blood pressure repeat gonorrhea culture e Post pregnancy check e Sickle cell blood sugar or other screening because of high risk status e Gestation check However prenatal exams are not included because they are not considered in the definition of family planning services e Emergency Contraception provided including history and counseling 4 Counseling Only The client receives specific family planning related consultation but no medical services are provided This consultation is recorded in the medical record See item 14A Counseling Services Provided for examples of counseling services 5 Pregnancy Test Visit The client s primary purpose for the visit is to receive a pregnancy test and counseling This visit may consist of just a urine pregnancy test or the urine pregnancy test and a pelvic examination The counseling service may be provided at another visit Code any additional medical services or counseling provided in this visit Note Any Purpose of Visit may be checked for a client s first visit since it is not linked to whether the client is a new or co
21. SSING CALENDAR Dates are approximate and depend on each calendar year Jan 3 Jan 15 Jan 25 Jan 30 Feb 5 Feb 15 Feb 15 Feb 25 Mar 10 Mar 15 Mar 25 April 7 April 15 April 25 April 30 May 15 May 25 June 7 June 15 June 25 July 8 July 15 July 25 November Processing Report completed by Ahlers Deadline for arrival of December CVR records to Ahlers December rejected CVRs returned to projects sites December processing reports completed by Ahlers Deadline for resubmission of rejected CVRs for inclusion in Annual Tables Region X Calendar Year Tables produced by Ahlers Deadline for arrival of January CVRs at Ahlers January rejected CVRs returned to projects sites January processing reports completed by Ahlers Deadline for arrival of February CVRs at Ahlers February rejected CVRs returned to projects sites February processing reports completed by Ahlers Deadline for arrival of March CVRs at Ahlers March rejected CVRs returned to projects sites Quarterly reports for Jan Mar produced by Ahlers Deadline for arrival of April CVRs at Ahlers April rejected CVRs returned to projects April processing reports completed by Ahlers Deadline for arrival of May CVRs at Ahlers May rejected CVRs returned to program by Ahlers May processing reports completed by Ahlers Deadline for arrival of June CVRs at Ahlers June rejected CVRs returned to projects sites 33 July 30 July 30 July 30 Aug 14 Aug 15 Aug 25 Sept 7 Sept 15 Sept 25 Oct 5
22. Sibssincascnsgsaxsccdsevscnsnsacduccudsansaadecbecnsssaciwesudnate 8 Dat of Birth sacsiesssaeecessnsacursaicnsneaiarea lt ieestin 8 GENGED Gacaiagicescanseiserdenacupanierueioansaseendenagunensasiataansencene 9 PPRMICIEY viinisansu csasnntensvaekesdialenie crane daguvacekeenesanesesavnadnes 9 RACE cists ssinasisgiesavevesingua EE 9 Additional Demo graplite cisicccisscccesssccasssecessssctussecvessscoees 10 PAY OG Cccceseunsassnnnsaswiweng ued E E EE Nees ies 10 Assigned Source of Payment cccsccssccescccsccccsccescceeess 10 Client Insurance Status wv ciisssssccsssssescsesevacecasscscvsevesessesees 10 Income and Family Size csccsscccscccsccccsccscccccsccsccceccs 11 Types of Income eseesessseessccssssosossssssssesecsesseesseeesooos 13 Precnancy HIStOPy isis scassecsasdarenssacecsimicasaecadseaiaussatacstatons 13 Purpose OF VISIGs iss sccssveuseccsvecsencssedessaeesenvensensdeeewseesewosees 14 Medical ServiCES ssssssssssossssscsssssosssssssssssessssssssss sestese dosos 15 Counseling Education sccsscccssevsccvecvecvcccossscesevessivevcevesss 19 Provider of Services ciccssssecisesevscesceisnn sever seieveversivessdawnsee 20 Primary Contraceptive Method scsscccssccssccsscccsscesecs 21 RRGr VANS sisiss seceidseaiecdsneseasnssedsededconsiesaw vis daniserendstiesiceies 22 3 National Title X Family Planning Annual Report Table ExplaniatiGins cise ccascecrecseadsvcccacssccdasacasessccevecasacseces 23 4 Exhibits
23. Vaginitis Urethritis Eval Rx Treatment of any vaginal genital or STD infection not specifically identified elsewhere under 13A Medical Services Provided i e Chlamydia or Warts 13 Chlamydia Treatment Providing treatment for a laboratory diagnosed case of Chlamydia Trachomatis CT 14 Chlamydia Presumptive Rx Prescribing medication to treat CT based on history e g contact with a confirmed case and or clinical findings This may be done without performing a CT test or prior to receiving the results of a test 15 Wart Treatment Treatment of external genital HPV infection with medication or cryotherapy This may include giving the client a prescription for self administered medication 16 Herpes Test Blood tests or cultures of lesions taken to diagnose Herpes Simplex Virus HSV 17 Diaphragm Cap Fit Assessment for proper fit and client instruction on use of diaphragm or cervical cap 19 IUD IUS Insert Insertion of an intrauterine contraceptive device or system into the uterus 20 Sterilization Procedure Any procedure on a man or woman intended to provide permanent contraception e g tubal ligation or vasectomy 21 Post Pregnancy Exam Physical assessment of a woman s health status with emphasis on uterine involution presence or absence of infection and family planning status following a pregnancy of any gestational age 16 22 IUD TUS Removal The intrauterine contraceptiv
24. ancer Screening A fecal sample placed on a card with chemical reagent to screen for blood in the stool 50 HPV Test A laboratory test using genetic viral typing to detect human papilloma virus HPV infection 18 2 14 Counseling Education Provided No 14A Refers to the non medical services listed in 14A which 1 inform a client about family planning and related services and supplies that are available and or 2 assist the client to clarify her his needs and examine alternatives available for meeting them Have the provider fill in this information at the time the service is given or have the data transcribed from the client s medical record at the end of the visit Counseling Education Services Defined Below is a list describing the counseling and education services found in 14A 1 Contraceptive Counseling Education Consultation information provided to a client regarding risks benefits and correct use of any birth control method being considered by the client This could also indicate general methods of education where birth control choices are briefly discussed and information provided in pamphlets etc 2 Fertility Awareness Method Counseling Education Consultation education provided to a client concerning the non medical or natural family planning techniques including mucous ovulation basal body temperature rhythm and related methods of natural fertility awareness 3 Sterilization Counseling Education Con
25. at home or college students 19 years of age and under who are dependent on family income Option 1 The teens consider themselves supported by their parents This will require estimation of parents income and the total number of people supported by the parents Option 2 The teen considers him or herself as a family of one only when confidential services are necessary Show the teen or student 19 years of age and under as a family size of one in CVR10b and enter any personal income derived from allowances or employment Fees may be waived for individuals with family incomes above this amount who as determined by the service site director are unable for good cause to pay for family planning services 10b How many people are supported by this income This category must have at least one as an answer 12 EXHIBIT A Types of Income The following sources of income should be included when computing gross income Salaries Wages Tips Help from relatives and non relatives Public Assistance Unemployment compensation Worker s compensation Veterans benefits Sick pay Social Security cash benefits such as widow s benefits and children s allowances Alimony Net investment income rent interest dividends Net earnings from self employment Pensions Annuities Royalties and commissions Business profits Also included in gross income should be deductions commonly taken out of income before client receives it These
26. cht com Dan Weiner Training Coordinator dan jba cht com Mailing address 1809 Seventh Ave Ste 400 Seattle WA 98101 1313 206 447 9538 FAX 206 447 9539 41
27. d to supply Ahlers with a contact e mail address They will upon request send tallies back of how many records were received after an electronic transmission How do we resubmit a CVR that has been rejected Simply correct the mistake on the CVR and resend it to Ahlers Since the first CVR was rejected by the system the second one will be accepted like a new CVR HIPAA How is the Region X Information System affected by HIPAA The Health Insurance Portability and Accountability Act of 1996 affects the transfer of medical information in that all information transferred via the internet email must be encrypted to protect the client s privacy The regional office the data processor the Information System manager and all the grantees have been working to meet all HIPAA guidelines and deadlines This manual includes a letter from Ahlers and Associates explaining some of the steps we are required to take to become and remain HIPAA compliant see the letter in the Exhibits section You may wish to visit www ahlerssoftware com and click on HIPAA where you will be able to access the three types of contracts the members of our Information System may be required to have a Clearing House contract a Data Accumulator Contract and or a Software Developer Contract These three types of relationships are explained in the letter The HIPAA section in the website also includes a link to WorksmartMD which has a demonstration package of software that include
28. deductions include Federal state and local taxes Social Security payments Deductions for savings bonds other savings plans or union dues The following are not income and should not be included in gross income Grants Receipt from sale of possessions Withdrawal from savings Loans Inheritance Maturity payments on insurance policies Lump sum compensation for injury or legal damages Tax Refunds Payment for foster parenting 2 11 Pregnancy History No 11 This item collects information on the number of live births fetal deaths and living children of female clients This item is left blank for male clients 11a How many times have you been pregnant 13 Ask the female directly or have them fill in the answer themselves if it has not been specified on the medical record Include all pregnancies regardless of outcome live birth stillbirth abortion or miscarriage Coding if the number is 9 or less put a zero in the first square such as 02 for two pregnancies If the client is pregnant for the first time during this visit write or code zero in the box 2 12 Purpose of Visit No 12 The Purpose of Visit is a code describing the primary reason for a visit Check only one box for the primary purpose Note ANY purpose of visit may be checked for the client s first visit to your clinic 1 Initial Medical Exam First comprehensive examination in which medical services 2 through 9 and appropriate lab services are
29. discussions regarding intimate partner violence or abuse and assault and steps the client can take to avoid violent situations 19 BSE Counseling Education Consultation education provided to a client by trained personnel regarding Breast Self Exam including encouragement of regular self breast exams 20 TSE Counseling Education Consultation education provided to a client by trained personnel regarding Testicular Self Exam including the encouragement of regular testicular self exams Note Make sure all counseling segments provided are recorded Counseling on the CVR must be recorded in the medical record Definitions of Providers 13B 14B Provider of Medical Services Counseling Education Services A provider is a trained individual whose primary responsibility is to assess the client s health status and exercise independent judgment regarding which services the client needs Physician Licensed doctors of medicine M D or osteopathy D O Mid level Physician s Assistants PA Nurse Practitioners ANP ARNP Certified Nurse Midwives CNM 20 Nurse Registered Nurses RN and Licensed Practical Nurses LPN Other Other service providers health educators social workers clinic aides and lab technicians 2 15 Primary Contraceptive Method No 15A Primary Contraceptive Method collects data on the contraceptive method the client used before the visit and the method the client will use as a result of the visit In the
30. e device is removed from the uterus 23 Hgb Hct A measurement of the hemoglobin Hgb content or the solids serum ratio Hct of capillary blood as an indirect assessment for anemia 24 Urine Dip Strip Urinalysis A narrow plastic strip containing chemical reagents that is dipped in a small amount of urine to provide a quick point of service check for sugar diabetes protein kidney problems and dehydration and white cells infection A urinalysis is a sample of urine submitted to a laboratory for a thorough evaluation with special equipment 25 Pap Test Conventional A sample of cervical cells taken during a speculum exam of the vagina and cervix to detect cervical dysplasia or cancer The sample is submitted to a clinical laboratory on a dry glass slide 26 Pap Test Liquid Based A sample of cervical cells taken during a speculum exam of the vagina and cervix to detect cervical dysplasia or cancer The sample is submitted to a clinical laboratory in a small vial or liquid preservative 27 Colposcopy An examination of the cervix vagina or vulva with a special microscope called a colposcope to detect abnormal cell changes 28 Gonorrhea Test A laboratory test performed to detect the bacterium Neisseria gonorrhoeae also called GC Testing specimens may be collected from the urethra vagina cervix rectum and throat Tests are also commonly performed on urine samples 29 Chlamydia Test A laboratory tes
31. elated Services Pregnancy Related Services and STD Related Services Medical Services 1 Procedures 2 9 and check appropriate lab services Allows staff to check one box that includes key components of the Title X physical exam 2 Blood Pressure Use of a stethoscope and blood pressure cuff to measure the force exerted on the walls of arteries as blood is pumped through them 15 3 Height Weight Measurements of client s height and or weight are recorded 4 Thyroid Exam Manual and visual examination of the thyroid to evaluate size shape symmetry or tenderness 5 Heart amp Lung Auscultation Evaluation of heart and lung sounds using a stethoscope 6 Breast Exam Visual inspection and palpation of the female male breasts to evaluate the symmetry of shape color size surface characteristics and for masses 7 Abdominal Palpation Visual inspection and palpation of the abdomen to evaluate for abnormalities 8 Extremities Inspection and or palpation of the arms and legs to evaluate for abnormalities 9 Bimanual Speculum Pelvic Exam Visual and or manual examination of the vulva vagina cervix and pelvic organs to detect any abnormalities and collect specimens samples for laboratory analysis when indicated 11 Vaginitis Urethritis Eval DX Evaluation of the vagina urethra and male female genital area via palpation visual inspection and or laboratory tests to detect infection 12
32. ent All of our clients need a Business Associate Agreement with Ahlers regardless of whether we are a Clearinghouse Data Accumulator and or Software Developer In fact you need one with any outside organization that has access to your clients protected health information This might include billing companies auditing firms attorneys etc If your organization has developed a Business Associate Agreement please forward it to Joe Ahlers for signature If you have not developed the Agreement you may print one from our website www ahlerssoftware com sign it and send it to Joe Ahlers for signature If you cannot access the website call for a copy to be mailed There are three Agreements on the website If Ahlers serves in two or more capacities for you Data Accumulator and Software Developer for example call Martha 800 888 1836 ext 100 and ask for a combined agreement Remember that HHS will not check Ahlers for this Agreement but your organization is subject to review 35 By When The Business Associate Agreement is part of the Privacy regulations and the deadline is April 14 2003 We urge you to send us an Agreement yours or ours before that date Are There Other Privacy Issues There are a couple of other Privacy issues that you and Ahlers must deal with by the April 14 deadline These relate to those of you who send us CVR data electronically versus paper and or for those of you who use Ahlers software In
33. er the number leading with zeros so that all nine boxes are filled For examples a client s number of 1122 is entered as 000001122 Client numbers must meet the following requirements e No two clients within a service site may have the same number e No two clients within a project may have the same number e The client number must not contain alphabetic or non numeric characters e The client number cannot be longer than nine digits The client number is used in conjunction with the date of birth field to ensure the correct data are matched to the right client Note It is suggested that if a project has multiple sites a prefix may be used to better identify clients from that particular site This will also help to avoid duplicates Example 1 The first site assigns a client number 100000789 2 The second site assigns client numbers 200000789 2 3 Date of Visit No 3 The date of visit is the date on which the client received medical and or counseling services at the service site The date is recorded in a month day year format The month and day should be converted to two digit numbers as shown below January 01 July 07 February 02 August 08 March 03 September 09 April 04 October 10 May 05 November 11 June 06 December 12 Example for client services on September 3 2008 the data entered into the box provided would be 3 Date of Visit 09 03 2008 The processor s computer will search for impossible dates and reject them I
34. ers Subject HIPAA 2003 promises to be the year of HIPAA for those of us in the healthcare industry Ahlers amp Associates has answered questions from some of you individually and has described what we are doing regarding HIPAA in our newsletters and CVR training sessions we have conducted The purpose of this letter is to summarize what we know and flag any action steps you will need to take This task is complex because Ahlers serves in up to three provider categories according to HIPAA If we receive CVR data from you and subsequently prepare billing to Medicaid Title XX Private Insurance and or to your state we are a Clearinghouse We serve this role in Texas Illinois and Oregon for all agencies and for several agencies in New York If we receive CVR data from you and accumulate those data into statewide reports management reports FPAR CL 7 etc but do not prepare billing on your behalf we are a Data Accumulator In addition to the states mentioned above this would include Alaska Idaho Washington Iowa Indiana Minnesota and Ohio If we have provided you with software into which CVR visits are recorded and or Client Billing Insurance Billing Pharmacy Lab Appointments we are a Software Developer In addition to the states mentioned above this would include Maine Rhode Island New Hampshire Virgin Islands Virginia North Carolina Michigan Missouri North Dakota and Nebraska Who Needs A Business Associate Agreem
35. f the CVR record is filled out after the visit date occurs record the date the client was seen in the clinic Note Only one CVR can be submitted for a client for one day If a client should make more than one visit on the same day all services provided to the client on that day should be coded on one CVR and the most inclusive exam is recorded for Purpose of Visit 2 4 Date of Birth No 4 The Date of Birth is the month day and year the client was born Record whatever information the client is able to give If the year of birth is unknown ask the client How old are you and calculate the year If the client does not know the month use July 15 This is a default date used by the processor for unknown data Record the client s date of birth in the code box in a month day year sequence Use the same two digit format used for Date of Visit Example If the client s date of birth is May 17 1963 the date entered into the box provided would be 4 Date of Birth 05 17 1963 Note It may be necessary to ask further probing questions of the client if she he does not know her his age or birth date Such questions might be centered on family events i e anniversaries parents ages etc or world events i e world wars presidents etc Date of birth is a control field on all CVR submissions and resubmissions but is not a control field for corrections and deletions See Section 1 2 5 Edit and Error Procedures A control field
36. g special federal funds for American Indians or male services state funds Donations should not be coded as a source of payment and are never reported on the CVR Note Remember this is how your site expects to be paid although it may not be the method that eventually covers the invoice If you expect to be paid by a combination of resources choose the one that would cover the largest portion of the invoice Note Idaho only may report Not reported All Idaho agencies will be allowed to code this response All other grantees must still code 01 07 for the CVR to be accepted The Source of Payment output now requires a 2 digit entry and the position in the transmission file has been moved from 155 to 158 159 2 9A Client Insurance Status No 18 This is a required answer for all visits The choices are 1 Public Health Insurance 2 Private Health Insurance 3 Uninsured 4 Unknown 10 To further clarify the following statements are from the FPAR Forms amp Instructions October 2007 A client has public or private insurance when Principal insurance is defined as the insurance plan program that the agency would bill first if a claim were to be filed Categories of health insurance covering primary medical care include public and private sources of coverage PRINCIPAL HEALTH INSURANCE COVERING PRIMARY MEDICAL CARE Refers to public and private health insurance plans that provide a broad set of primary medical care benefits
37. ices physical assessment treatment and management relating to a client s 24 proposed or adopted method of contraception general reproductive health or infertility treatment in accordance with the Program Guidelines OTHER SERVICES PROVIDER Includes other agency staff e g registered nurses public health nurses licensed vocational or licensed practical nurses certified nurse assistants health educators social workers or clinic aides that offer client education counseling referral or follow up services relating to the client s proposed or adopted method of contraception general reproductive health or infertility treatment as described in the Program Guidelines Other services providers may also perform or obtain samples for routine laboratory tests e g urine pregnancy STD and cholesterol and lipid analysis give contraceptive injections e g Depo Provera and perform routine clinical procedures that may include some aspects of the user physical assessment e g blood pressure evaluation in accordance with the Program Guidelines FAMILY PLANNING ENCOUNTER A family planning encounter is a documented face to face contact between an individual and a family planning provider that takes place in a Title X service site The purpose of a family planning encounter whether clinical or non clinical is to provide family planning and related preventive health services to female and male clients who want to avoid uninte
38. ield Values Effective January 1 2009 RED NOTES CHANGES ield Description Valid Codes for each Field fe i inic Number assigned by Region X elf Explanatory CYYMMDD 2 3 4 5 Only Medical Services Providers of Medical Counseling DESCRIPTION CHANGES ee ee Counseling Services 01 02 03 04 05 06 07 08 09 10 12 13 15 16 17 18 19 20 Clinic Site Number Client Number k Revision Number Contraceptive Method Before 01 02 03 04 06 07 08 09 10 11 13 14 15 16 17 18 19 DESCRIPTION CHANGE Reason for No Method DESCRIPTION CHANGE Ahlers Internal Use ource of Payment Ahlers Internal Use Monthly Income amily Size nsurance Status 1 2 3 or 4 Zip Code elf Explanatory 02000 and Greater thnicity Gender Ahlers Internal Use Zero Fill Additional Demographics Face Ahlers intemal Use Clinic Site Number i Client Number sd Purpose of Visit Date of Birth Medical Services sid DESCRIPTION CHANGES ae ee Providers of Medical Counseling DESCRIPTION CHANGES si Counseling Services i DESCRIPTION CHANGES Revision Number Contraceptive Method Before DESCRIPTION CHANGE Contraceptive Method After DESCRIPTION CHANGE Reason for No Method Referral Information DESCRIPTION CHANGE Ahlers Internal Use i Number of Pregnancies Ahlers Internal Use i Monthly Income sd Zip Code ooo O Gender o O Ahlers Internal Use O Z Additional Demographics Race O Ahlers Internal Use Cid 32 Exhibit 5 PROCE
39. ly be a guideline for a computer system that records the required information When should a CVR be completed e For all initial annual and other medical or STD visits as long as the client is receiving family planning medical and or counseling services and a client record is established and updated for each visit These visits are valid for both female and male clients e For outreach off site services that meet the criteria of a family planning visit e For pregnancy test visits where testing and professional counseling services related to pregnancy test results are provided and recorded on the client record e For vasectomy visits that include professional counseling services and establishment of a client record e For counseling only visits where the information is placed in the client record e For emergency contraceptive visits if they include counseling and establishment or update of a client record e Clients using abstinence or sterilization as their contraceptive method may also receive family planning services The tool The CVR Clinic Visit Record The CVR is a regional or in some cases state specific tool for collecting raw data For some projects and clinics this may be a paper document In most it is the basis for a section of a computerized billing client Information System Whether you use the paper CVR or it is built into your computer system the tool is the same and the definitions and the guidelines for
40. m Cap 08 NFP FAM 11 Hormone Implant 13 Abstinence 15 IUS 14 Male Sterilization 16 Hormonal Injection 3 month 20 Withdrawal 17 Hormonal Patch 21 Contraceptive Sponge 18 Vaginal Ring 10 None Berore visit _ _ AFTER VISIT 15B IF NONE AT THE END OF THIS VISIT GIVE REASON Pregnant C 3 Seeking Pregnancy 1 Planned 8 Unplanned 16 Not Sexually Active 7 Other 16 REFERRAL INFORMATION Check all Applicable 102 High Risk Pregnancy 05 Sterilization 10 Social Sevices _ 15 Adoption C106 Infertility _J 09 Nutrition L 03 Abortion 07 NFP FAM L 13 Substance Abuse L 01 Prenatal c04 STD L 14 Abuse Violence LJ 16 Breast Evaluation C 17 Colposcopy 11 None LJ 12 Mammography or 08 Other Medical U S FORM 16 REV 01 2009 VER 0901 28 Exhibit 2 Region X File Specifications for 3rd Party Vendors Effective January 1 2009 Field Description Format susty Length Record Oooo d Position Site Clinic Number Client Number Date of Visit CCYYMMDD Purpose of Visit Values 1 5 Date of Birth CCYYMMDD Medical Services Provider of Medical Counseling Services Alphameric Counseling Services Alphameric Revision Number 0901 136 139 Beginning Contraceptive Method Alphameric 140 141 Ending Contraceptive Method Alphameric If None Give Reason Alphameric_ Left 142 143 Referral Inf
41. n Services DHS 800 NE Oregon St Ste 370 Portland OR 97232 FAX 971 673 0371 39 Washington State DOH Idaho Dept of Health amp Welfare Sharon McAllister Program Director Family Planning amp Reproductive Health 360 236 3403 sharon mcAllister doh wa gov Gayla Gilmore Title X Grant Coordinator 360 236 3454 gayla gilmore doh wa gov Chris Knutson Public Health Nurse Consultant 360 236 3469 chris knutson doh wa gov Mailing Address Washington DOH P O Box 47883 Div of Community amp Family Health Olympia WA 98504 7883 FAX 360 236 3400 Ella Gordon Reproductive Health Coordinator 208 334 5616 gordone dhw idaho gov Kathy Cohen RH Program Manager 208 334 6526 cohenK dhw idaho gov Mailing Address Bureau of Clinical amp Preventive Health Services Division of Health DHW 450 W State St 4 Floor P O Box 83720 Boise ID 83720 0036 FAX 208 334 4914 Alaska Dept of Health amp Social Services Kelly Keeter Family Planning Program Manager 907 269 3461 kelly keeter alaska gov Sherrell Holtshouser Family Planning Nurse Consultant 907 269 3426 Sherrell holtshouser alaska gov Mailing Address State of Alaska DHSS Division of Public Health Women s Children s amp Family Health 3601 C St Ste 322 Anchorage AK 99503 FAX 907 269 3432 Municipality of Anchorage DHHS Becky Morisse RHC Program Manager 907 3
42. nded pregnancies or achieve intended pregnancies To be counted for purposes of the FPAR a written record of the service s provided during the family planning encounter must be documented in the client record There are two types of family planning encounters at Title X service sites 1 family planning encounters with a clinical services provider and 2 family planning encounters with an other services provider The type of family planning provider who renders the care regardless of the services rendered determines the type of family planning encounter Although a client may meet with both clinical and other services providers during an encounter the provider with the highest level of training who takes ultimate responsibility for the client s clinical or non clinical assessment and care during the visit is credited with the encounter FAMILY PLANNING ENCOUNTER WITH A CLINICAL SERVICES PROVIDER A face to face documented encounter between a family planning client and a clinical services provider that takes place in a Title X service site FAMILY PLANNING ENCOUNTER WITH AN OTHER SERVICES PROVIDER A face to face documented encounter between a family planning client and an other services provider that takes place in a Title X service site Laboratory tests and related counseling and education in and of themselves do not constitute a family planning encounter unless there is face to face contact between the client and provider the p
43. nsert a flexible matchstick sized rod containing small amounts of a contraceptive hormone 39 Hormone Implant Out A surgical incision made to remove an implanted contraceptive hormone rod 40 Hormonal Injection An intramuscular or subcutaneous injection of the contraceptive hormones progestin 42 Male Genitalia Exam Examination of the external male genitalia via visual inspection and palpation to detect any abnormalities 43 HIV Test Standard A laboratory test performed by a reference laboratory outside lab by any means blood saliva to detect the presence of human immunodeficiency virus HIV antibodies Results are typically received by the clinic in 5 15 days 44 HIV Test Rapid A laboratory test performed at the point of client service by any means blood saliva to detect the presence of human immunodeficiency virus HIV antibodies Results are typically available in 20 min 46 EC Future Need Prescription or product given for future use with instructions to use in the event of unprotected intercourse or birth control failure e g broken condom 47 VDRL RPR Venereal Disease Research Laboratory Test Rapid Plasma Reagin blood test for syphilis a sexually transmitted infection 48 EC Immediate Need Oral contraceptive pills prescribed or provided with a specific regimen to be used as soon as possible after unprotected intercourse to prevent pregnancy 49 Colo Rectal C
44. ntinuing client If it is the client s first visit all items on the CVR must be completed If not only items 1 4 9 and 12 16 must be completed 2 13 Medical Services Provided No 13A Check all that apply Medical Services Provided includes the examination laboratory diagnostic and treatment procedures listed in 13A provided to a client during the visit These services have been divided into four categories Exam and Lab Services Contraceptive Related Services Pregnancy Related Services and STD Services The medical provider should fill in this information at the time the services are given or it can be transcribed from the client s medical record at the end of the visit Check the corresponding boxes for all medical services provided For convenience checking number 1 includes all items 2 9 so make sure all applicable lab services are also checked Males may have breast exams checked on the CVR Chlamydia presumptive treatment CVR 14 in is based upon symptoms For 13A check 36 Other only if the medical services provided were in conjunction with other reproductive services such as related services and not listed on the CVR Check 37 None if it is a Counseling Only visit and no medical services were provided Medical Services Defined The following is a list of descriptions of the medical services in CVR 13A They are listed by the four categories on the CVR Exam amp Lab Services Contraceptive R
45. on the number of Gonorrhea Syphilis and HIV Tests during the period These are important indicators for family planning providers and include all individuals who have received at least one of the named tests during the period FPAR TABLE 13 NUMBER OF FAMILY PLANNING ENCOUNTERS BY TYPE OF PROVIDER This table reports the number and type of encounters for Clinical Services Providers and for Other Services Providers The number of FTE s full time equivalent must be reported by the agency TERMS AND DEFINITIONS FAMILY PLANNING PROVIDER A family planning provider is the individual who assumes primary responsibility for assessing a client and documenting services in the client record Providers include those agency staff that exercise independent judgment as to the services rendered to the client during an encounter Two general types of providers deliver Title X family planning services clinical services providers and other services providers CLINICAL SERVICES PROVIDER Includes physicians family and general practitioners specialists physician assistants nurse practitioners certified nurse midwives and registered nurses with an expanded scope of practice who are trained and permitted by state specific regulations to perform all aspects of the user male and female physical assessment as described in Program Guidelines Clinical services providers are able to offer client education counseling referral follow up and clinical serv
46. ormation Alphameric Left Ahlers Internal Use Alphameric Left Number of Pregnancies Alohameric Right Zero Fill Source of Payment 158 159 Ahlers Internal Use 160 161 Monthly Income Number Supported b Income i Right Zero Fill 162 167 Insurance Status ic Left Zip Code Hispanic 6 Yes or 9 No Gender gt M INIOJINI INJINJ gt OJ NM VM H amp 177 177 Ahlers Internal Use 178 261 Additional Demographics Races Ahlers Internal Use Please See Following Pages for Codes and Values in Fields Any field highlighted in Red has some type of change Please see the attached Field Values and Attachment Listings All Alphameric Fields are Blank Filled Unless Otherwise Specified All Numeric Fields are Zero filled Unless Otherwise Specified End of Record must be Carriage Return Line Feed 29 Exhibit 3 Region X 3rd Party Vendor File Specifications Effective January 1 2009 Attachments A G RED NOTES DESCRIPTION CHANGES OR ADDITIONS Races Attachment A Ethnicity Attachment B 1 White 6 Hispanic or Latino 2 Black African American 9 Not Hispanic or Latino 3 American Indian 4 Alaska Native 5 Asian 6 Other 7 Unknown or Not Reported 8 Native Hawaiian Pacific Islander Code as many races in Attachment A as applicable RED NOTES DESCRIPTION CHANGES OR
47. page is perforated the top sheet should be torn off and submitted to Ahlers and Associates for collection into the regional system 2 1 Service Site Number No 1 The service site number is the number assigned to your agency by the data processor and the Information System manager for use in the Region X Family Planning Information System If you do not have a number please contact your administrative office and the state grantee who will then contact the processor and the IS manager to obtain a number for your site Please use only the service site numbers approved for this system When completing this item always enter the number with leading zeros so that all seven boxes are filled For example if a site number is 4321 it is entered as 0004321 2 2 Client Number No 2 The client number is a number assigned by your agency to the client Nine digits are available for this number This number should be taken from the medical records or other client information files Each agency may have its own procedures for creating new client identification numbers Always use care to avoid using duplicate numbers If a client has been absent from your system for thirty six months or more the processor s system will discontinue the client number However the old number can be reassigned to the client or a new one can be created Be careful not to assign the old number to someone else As always if the number is fewer than nine digits always ent
48. provided see item 13A Medical Services Provided and contraceptive counseling and education are given This examination does not necessarily occur during the client s first visit to the agency Therefore the Initial Medical Exam visit is not necessarily the same as first visit to the service site 2 Annual Medical Exam Subsequent visit often provided annually at which time the client receives a comprehensive medical examination This exam was previously required by the Title X Program but it has been changed to a time that is based on client need clinician judgment and standards of practice Medical services 2 through 9 and appropriate lab service should be provided during this visit Other services may also be provided 3 Other Medical One or more medical services are provided for routine contraceptive sterilization or infertility or related care Counseling services may also be provided This includes e Contraceptive follow up such as hormonal method supply IUD contraceptive injection and diaphragm check e Method prescription without complete physical exam and lab services e g pill prescription diaphragm fit UD insertion e Follow up to the initial or annual medical exam visit because all services were not provided at that time e Vasectomy or tubal ligation if performed on site e Infertility consultation if medical or lab services are provided If not the visit should be coded as Counseling Only See CV
49. r any income the client may receive as a result of the arrangement e g rent is considered income contributed to her him and should be counted Foster children or other 11 unrelated children living in a household are not considered part of the family and payments received for caring for foster children is not considered as income Help the client add all the incomes of her his family and enter the actual amount on the CVR It may be helpful to skip to the next question and find out how many people are supported by this income and then determine the income of each of these people Enter the actual numeric amount in whole dollars For example if the income is 431 41 enter 431 If the client is a full time salaried employee base the average gross monthly income on the client s most recent month s income If the client works part time works on a commission basis or otherwise has an unsteady income base the average gross monthly income on the client s average gross monthly income for the previous twelve months Some clients may know only the amount of their take home pay or net income To calculate gross income multiply the net income take home pay by 1 15 This process will need to be done for all contributing members of the family The determination of income CVR 10a and family size CVR10b for teens and college students 19 years of age and under is difficult yet important There are two options for teenagers that live
50. rovider documents the encounter in the client s record and the test s is are accompanied by family planning counseling or education FULL TIME EQUIVALENT FTE For each type of clinical services provider report the time in FTEs that these providers are involved in the 25 direct provision of Title X services i e engaged in a family planning encounter 26 4 0 Exhibits Exhibit 1 REGION X CLINIC VISIT RECORD NAME Last First my Client Date of Visit Address City State Zip Phone DETACH THIS PORTION AND RETAIN AT SERVICE SITE 1 SERVICE SITE NUMBER 13A CONT MEDICAL SERVICES Check all Applicable Contraceptive Related Services Pregnancy Related Services 2 CLIENT NUMBER DAY YR 3 DATE OF VISIT 2 0 MO DAY YR 4 DATE OF BIRTH 1 9 5 GENDER C 1 Female 2 Male 6 ETHNICITY LJ6 Hispanic or Latino _J 9 Not Hispanic or Latino 6a RACE Mark All That Apply L 1 White L 4 Alaska Native L2 Black Afr Amer C 5 Asian C3 American Indian L17 Unknown Not Reported L6 Other 7 ADDITIONAL DEMOGRAPHIC Check if Applicable C 5 Limited English Proficiency 8 ZIP CODE 9 ASSIGNED SOURCE OF PAYMENT Check One _ 1 No Charge 5 Full Fee C2 Title XIX Medicaid 16 Partial Fee 13 Take Charge Project 17 Other L 4 Private Insurance L19 Not Reported Idaho 18 CLIENT INSURANCE STATUS Check One L 1 Public Heal
51. s sections on compliance training assessment forms and implementation guides There are many websites that contain HIPAA information as well Two very comprehensive sites are http aspe hhs gov admsimp which includes the option to subscribe to a HIPAA registration list that sends regular updates on the law to your email address Another site www hipaa org is comprehensive and covers many aspects of the law and its implementation Output How does the regional Information System help me The Information System provides those in family planning with statistical reports broken down by the portions of time in which they are submitted quarterly calendar year fiscal year July thru June FPAR Dec 1 thru Nov 30 of the following year and special requests These reports are provided at no additional charge to the project and clinic sites CVR data is reported by each agency project and at each registered clinic site within the project Projects The project is the administrative unity of a family planning program A project may have one or many sites where family planning services are provided Forms and reports are usually sent to the projects Service Site The service or clinic site is the location where services are actually provided Data reports may be obtained as mailed paper reports on diskette by using a small DOS shell program called Report Viewer which is provided by Ahlers at no additional charge or on the Ahlers websi
52. sk the client to fill out this category What race or races do you identify with Again it is important not to draw conclusions about a client s race The choices are 1 White 3 American Indian 5 Asian 2 Black African American 4 Alaskan Native 6 Other 7 Unknown Not Reported 8 Hawaiian Pacific Islander 2 7 Additional Demographic No 7 Limited English Proficiency LEP This is checked when a client has limited ability to read speak or understand English and may need assistance to optimize his her use of family planning services If the staff must speak in the client s native language or if a third person is used to communicate with staff client this item should be checked 2 8 Zip Code No 8 This item is used to determine the location of the client s residence Enter the zip code provided by the client Blanks are not accepted 2 9 Assigned Source of Payment No 9 Assigned source of payment indicates how your service site expects to be paid for the services provided during the visit Check the appropriate box if the client qualifies for one of the following e 2 Title XIX Medicaid or welfare 3 Take Charge Project WA Medicaid Waiver Program e 4 Private Insurance Otherwise use your service site fee schedule to indicate whether the amount to be charged the client is 1 Nothing no charge 5 Full Fee 6 Partial Fee Other may be used when other third party payers are charged e
53. st and cervical cancer testing and counseling for sexually transmitted diseases including HIV infertility services and reproductive health education and referrals Source OPA website www hhs gov opa Title X is not to be confused with Region X Most federal agencies divide the United States into 10 regions designated by Roman numerals I though X The Northwest United States Washington Oregon Idaho and Alaska is designated as Region X Our region and Title X share a roman numeral but they are not related What is the Region X Family Planning Information System For over 20 years our region has collected data on Title X clients in order to Describe Family Planning Clients who receive Title X services in Region X Construct funding and internal reports Plan resources Measure Outcomes Analyze clinic effectiveness and efficiency Provide accurate and timely reports of client data to the Regional Office grantees and clinic staff AMMOADS In addition aggregate data based on client clinic visits are submitted annually to OPA A data contractor compiles the national Family Planning Annual Report FPAR for OPA describing Title X clients and services Who Oversees and Monitors the Information System A contractor manages the information system A Regional Advisory committee consisting of the Family Planning Regional Program Coordinator and several Title X Grantees monitors the program and makes recommendations for any needed
54. sultation education provided to a client by trained personnel regarding a permanent birth control method i e tubal ligation or vasectomy 4 Infertility Counseling Education Consultation education provided to a client or couple by trained personnel concerning the inability of a client or couple to conceive 5 Tobacco Counseling Education Consultation education provided to a client by trained personnel regarding the assessment of tobacco habit use its relationship to birth control and general health and assistance with resources to promote cessation 6 Substance Abuse Counseling Education Consultation education and information provided to a client by trained personnel concerning substance use habits and the relationship between use abuse and health This may include education on self assessment risk reduction goal setting and behavior change 7 Pregnancy Options Counseling Education Consultation education provided to a client by trained personnel regarding pregnancy testing its limitations and all pregnancy options 8 Preconception Counseling Education Information and counseling regarding conception including rubella genetics and all other factors that can affect a pregnancy Identification of possible pre pregnancy risks and provision of health education are given to help women couples make informed choices about future childbearing 9 STD HIV Prevention Counseling Education Consultation education provided to a client by
55. t performed to diagnose Chlamydia Trachomatis also called CT Endocervical and urethral samples are taken during a pelvic exam Clients may self collect samples using vaginal swabs Tests are commonly performed on urine samples 30 Wet Mount A microscopy procedure to detect vaginitis by visually scanning a sample of vaginal discharge on a slide prepared with saline and or KOH 31 Serum Pregnancy Test A blood test to detect pregnancy soon after conception and before a missed period useful for assessing suspected ectopic or molar pregnancy when performed in a series Also called a quantitative pregnancy test 32 Negative Pregnancy Test A negative test either by serum or urine HCG as part of the pregnancy diagnosis 33 Positive Pregnancy Test A positive test either by serum or urine HCG testing as part of a pregnancy diagnosis 34 Immunization Providing vaccinations for a variety of diseases including but not limited to Hepatitis B HPV and Rubella 35 Infertility Screening A basic Level 1 screening that includes an initial infertility interview education physical exam counseling and appropriate referral 36 Other Lab or Exam Medical services provided in conjunction with other reproductive services and other related services 17 37 No Lab or Exam No medical or laboratory services were provided This is a counseling only visit 38 Hormone Implant In A surgical procedure to i
56. te at www ahlerssoftware com To obtain access to the on line reporting portion of the website you must request a user ID and password from Ahlers and Associates A password application is available in the exhibits section of this manual Website features Ahlers website address is www ahlerssoftware com After entering the website the user may log in and gain access to a variety of standardized data reports for quarterly calendar and fiscal time periods Users may search for specific projects or service sites see above for definitions Access to these reports depends on the security clearance of each individual The website also hosts a data query section for advanced statistical research This section is designed for technical personnel who create databases and are experienced in data downloads and working with DBF database file formats Examples and explanations of the standardized data reports are included in section 3 0 of this manual 2 0 How to collect CVR data 2 0 How do I complete each section of the CVR The following list is a description of the numbered components of the CVR and directions for coding them into a computer system or filling out the paper version The top portion of the CVR pertains to client demographics and is intended solely for the use of the clinic site or administrative agency This information is not gathered in the Regional Information System If you are using a paper CVR the top portion of the first
57. th Insurance J 2 Private Health Insurance 8 Native Hawaiian Pacific Islander C 17 Diaphragm Cap Fit _ 21 Post Pregnancy Exam C 19 IUD IUS Insert C131 Serum Pregnancy Test 20 Sterilization Procedure 132 Negative Pregnancy Test 138 Hormone Implant In C33 Positive Pregnancy Test 139 Hormone Implant Out 135 Infertility Screening 140 Hormonal Injection _ 48 EC Immediate Need _ 46 EC Future Need _ 22 IUD IUS Removal STD Related Services L 11 Vaginitis Urethritis Eval Dx L28 Gonorrhea Test C 12 Vaginitis Urethritis Eval Rx L130 Wet Mount C 29 Chlamydia Test _ 43 HIV Test Standard C 13 Chlamydia Treatment 44 HIV Test Rapid LJ 14 Chlamydia Presumptive Rx 47 VDRL RPR L 15 Wart Treatment 50 HPV Test _ 16 Herpes Test JODLI 14A COUNSELING EDUCATION PROVIDED Check all Applicable C101 Contraceptive C 09 STD HIV M18 Relationship C102 Fertility Awareness Prevention Safety Method LJ 10 HIV Pre amp Post C 12 Nutrition L103 Sterilization _ 16 Abnormal Pap 1 05 Tobacco LJ 04 Infertility 119 BSE C 06 Substance L08 Preconception L20 TSE Abuse L 13 Abstinence L 15 Crisis 07 Pregnancy Options C 17 Encourage Parental Family Involvement C13 Uninsured J 4 Unknown 10 INCOME AND FAMILY SIZE AMOUNT a What is your monthly family income b How many people are in your
58. the past we have accepted CVR data electronically via Email BBS or FTP In April the electronic transmission of client data must be encrypted and that cannot be done in Email or BBS FTP qualifies as will our website in the next couple of months We will furnish our Windows CVR clients with a program update which will automatically send transmission to our FTP server Third party non Ahlers software transmitters users will need to acquire an encryption program to protect your client information You may do this by acquiring an SSL enabled FTP client We recommend WSFTP by IPSWITCH You can download an evaluation version at www ipswitch com or purchase it for 39 95 Because we have a Verisign Certificate of Authentication your data can only be read by our computer Additionally your Ahlers software must be updated for these features Unique User ID and Password which provides security for each module For example a staff member may be able to access CVR but not Client Billing Time Out Feature for each workstation must be provided Should the staff person leave the workstation unattended for a defined time period the screen will go to a screen saver This prevents other staff from accessing information that only the absent staff person is authorized to view A Disclosure Log is necessary Some clinics may maintain this log manually or outside the software This is something your clients have the right to request and receive It shows
59. ther plan that covers a broad set of primary medical care benefits 2 10 Income and Family Size No 10 This question requires that the client be asked directly for the information In order to help the client answer correctly the following definitions should either be read to the client or discussed with her him Income The gross average monthly income is all money coming in which contributes to the support of the family Exhibit A page 13 lists the various sources of income to be included When requesting income information make every attempt to get an actual or estimated figure from the client When clients do not know their income assist them in estimating it Family A social unit composed of one person or two or more persons living together as a household A household includes all the persons who occupy a housing unit Household members do not need to be married to be counted in household income dependents away at school also are included The income of all these persons should be counted to calculate the total income of the family Examples of what constitutes a family include a married couple with or without children one parent with one or more children a married couple sharing the home of a husband s or wife s parents two related married couples sharing a single household and minors living on their own Single persons who are living together are not considered a family and should be considered as a family of one Howeve
60. to enrolled individuals Report the most current health insurance coverage information available for the client even though he or she may not have used this health insurance to pay for family planning services received during his or her last encounter For individuals who have coverage under more than one health plan principal insurance is defined as the insurance plan that the agency would bill first i e primary if a claim were to be filed Categories of health insurance covering primary medical care include public and private sources of coverage UNINSURED Refers to clients who do not have a public or private health insurance plan that covers broad primary medical care benefits Clients whose services are subsidized through state or local indigent care programs or clients insured through the Indian Health Service who obtain care in a non participating facility are considered uninsured A client is insured if 1 he or she is enrolled in a Medicaid family planning expansion program that covers a broad set of primary medical care benefits in addition to family planning or 2 he or she is enrolled in a Medicaid expansion program that covers only family planning services and he or she has coverage under another plan that covers a broad set of primary medical care benefits A client is uninsured if he or she is enrolled in a Medicaid family planning expansion program that covers only family planning services and he or she has no coverage under ano

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