For many FQHCs today, the pressure to meet quality benchmarks has never been greater. Shrinking Medicaid budgets, increasing patient complexity, and the expectation to perform well on both HEDIS and UDS reporting can leave clinics stretched thin. Now, with only one quarter left to capture 2025 exclusions for UDS, the stakes are even higher. Missing eligible Advanced Illness and Frailty (AIF) exclusions can skew your quality data, misrepresent patient complexity, and impact both funding and strategic decisions.
Understanding AIF exclusions is critical. When applied correctly, these exclusions protect performance metrics, allow care teams to focus on patients who can benefit most, and ensure HEDIS and UDS reports reflect the true complexity of your patient population.
Why Exclusions Exist: Bringing Realism Into Measurement
AIF exclusions aren’t loopholes—they are safeguards designed to align quality metrics with patient realities. When applied correctly, exclusions:
- Protect quality scores from distortion by recognizing when interventions aren’t clinically appropriate.
- Improve efficiency by removing members who would not benefit from outreach, allowing teams to focus on actionable care.
- Support risk adjustment and funding alignment by giving a truer picture of patient complexity—essential for reimbursement and advocacy.
In the UDS context, these principles ensure national reporting accurately reflects the burden and diversity of care delivered at community health centers. Correct exclusions prevent false gaps in performance rates while still capturing the full scope of services provided.
Breaking Down the Requirements
To apply AIF exclusions effectively:
- Advanced Illness: Conditions like end-stage renal disease, metastatic cancer, severe COPD, or advanced heart failure may qualify. Documentation must appear twice in the current measurement year, or once in both the current and prior year.
- Frailty: Frailty can be established with two diagnoses on different service dates in the same year, or one frailty diagnosis paired with an advanced illness. Examples include dependence on a wheelchair (Z99.3), need for personal care assistance (Z74.1), multiple falls (R29.6), or long-term nursing care.
- Settings That Apply: Evidence may come from outpatient encounters, hospital discharges, emergency visits, and often telehealth visits, depending on the measure.
These details matter because exclusions only hold value when consistently supported by documentation and coding. Without that foundation, eligible exclusions risk being missed—especially in this final quarter of the reporting year.
The Bigger Picture: UDS and Organizational Strategy
While HEDIS measures focus on specific conditions and screenings, UDS paints a broader portrait of community health. Patient demographics, clinical outcomes, staffing, and financials all tell the story of your organization’s impact.
Just as AIF exclusions protect HEDIS scores from distortion, accurate UDS reporting ensures your health center is represented fairly in national benchmarks. It helps HRSA allocate funding, informs local strategy, and strengthens advocacy efforts. When advanced illness and frailty are coded correctly, they also influence risk adjustment, ensuring resources align with the true complexity of the populations you serve.
Why This Matters Now
With only one quarter left in 2025, healthcare leaders must act quickly. Both HEDIS and UDS rely on accuracy—not just in reporting what was done, but in clarifying when measures should not apply. Exclusions like AIF allow quality data to reflect clinical appropriateness rather than a one-size-fits-all standard.
Quality reporting isn’t just compliance—it’s an opportunity. Done well, it tells a story that is credible, compelling, and complete. By investing in documentation accuracy, coding education, and cross-team collaboration now, organizations can ensure their data reflects the full reality of the patients they serve.
For FQHCs and community health centers ready to capture all eligible exclusions before the 2025 UDS deadline, BCA’s audit, education, and consulting services provide the guidance needed to optimize reporting, strengthen HEDIS and UDS performance, and safeguard your funding and quality scores.
Connect with an expert today.