Provider Manual - Show Me Healthy Women (SMHW)


Section 4 - SMHW Screening Recommendations

Screening Recommendations

Routine screening and early detection are vital to reducing morbidity and mortality from breast and cervical cancer. Regular screening and early detection decreases mortality and improves quality of life for all individuals. Regular clinical breast exams, mammography, pelvic exams, and pap tests are the best screening methods available for breast and cervical cancers and pre-cancerous conditions.

Provider Responsibilities

  • Schedule annual breast and cervical cancer screenings appropriately for clients.
  • Notify clients in advance of recommended screening dates. If the client does not schedule an appointment after the first notification, a second attempt shall be made.

Initial Screening

The initial screening is:

  • The first screening performed on a woman by a SMHW provider.

OR

  • If a client has not been seen for five years for a SMHW screening by the same provider.

NOTE:

Initial clients need to complete a SMHW green history form (pages 10.8 [English] and page 10.9 [Spanish]) or download a copy here.

 

Annual Screening

The annual screening is:

  • The process of returning for an annual screening test at a predetermined interval. SMHW defines an annual screening to be 10 months or greater from the initial screening.

NOTE:

Annual clients need to review and update the green history form at each annual visit either by completing a new form or by reviewing and initialing updates and initialing the new form with the date of the current visit.

Rescreening

Rescreening is:

  • An additional screening visit resulting from an abnormal initial or abnormal annual screening that is less than 10 months from an initial or annual screen.

NOTE:

If there is a delay in the rescreening visit for 10 months or more from the date of the annual/initial visit, reimbursement occurs only after the rescreen meets breast/cervical criteria for an annual screening.

Green History Form

All forms are annually associated with their specific grant year. When submitting an electronic or a paper form, use the version of the form that is the grant year which corresponds with the date of service. At the beginning of each grant year, there are multiple versions of this form available in Missouri Health Strategic Architectures and Information Cooperative (MOHSAIC). Click on the correct version when entering electronic forms. If using paper forms, check for the year of the form in the lower left corner: example (3/14).

NOTE:

All clients who participate in SMHW must complete a Patient History Form, also referred to as green history form, at the initial screening. The green history form is available in English and Spanish. Assistance may be given to the client for completion of the form. To order blank forms from SMHW call toll-free at 866-726-9926 or 573-522-2845.

  • Information from the green history form is used to verify a client’s eligibility for screening, as well as statistics to evaluate the program. Some information from the green history form is also reported to the Centers for Disease Control and Prevention (CDC). Keep all information confidential.
  • The information on the original form shall be entered electronically in the MOHSAIC system. File all reported information in the client’s record.
  • Access MOHSAIC electronic forms at this link.
  • A copy of the green history form is located on page 10.8 [English] and page 10.9 [Spanish] or download a copy here.
  • If you have additional questions, please call SMHW toll-free at 866-726-9926 or 573-522-2845 for general assistance with central office staff.

If you have questions or concerns regarding specific issues with MOHSAIC, contact the ITSD Help Desk by telephone at 800-347-0887 or by e-mail at support@health.mo.gov.

Clinical Requirements for SMHW Services

The screening services outlined in the following pages are clinical requirements and shall be completed by the provider of SMHW services in order to be considered for reimbursement. Age restrictions and income guidelines always apply. Providers must have the capability to provide or offer access to the following services:

Comprehensive Breast and Cervical Screening

  • Clinical Breast Exam (CBE) provided annually for all women
  • Assessment for High Risk for breast and cervical cancer
  • Client education on the importance of obtaining screenings for breast and cervical cancer according to the appropriate screening schedules
  • Routine screening mammogram offered annually or every other year per clinician and client determination, beginning at age 40 and over. (Table 1, page 4.6):
  • Special circumstances include:
    • Offer a mammogram annually if a woman has a personal history of breast cancer
    • Any client, age 21 or older, who currently has abnormal breast exam results, can receive diagnostic mammograms and other necessary breast diagnostic services covered by the SMHW program
  • Complete visual and manual pelvic examination
  • Pap test, conventional or liquid-based, HPV test at appropriate intervals (Table 2, page 4.7)
  • Documentation of providing screening examination results to clients per verbal report or in writing
  • Appropriate and timely case management for all clients with suspicious or abnormal results, including rescreening, diagnostic procedures and/or treatment

Annual Screening Protocol

Age restrictions and income guidelines always apply to a client’s eligibility for the services described below.

Breast Cancer Screening

  • A Clinical Breast Exam (CBE) is recommended by SMHW for a complete screening and is a reporting requirement of the grant. Coordination of a full screening with health care providers is expected. Perform a CBE annually, as needed, on all women, especially if they have had previous breast cancer surgery.
  • CBE is not required for reimbursement of a mammogram. Provide an annual mammogram to clients with a personal history of breast cancer at the clinician’s discretion.
  • SMHW will reimburse for an annual breast cancer screening after ten (10) months have lapsed from the previous annual breast cancer screening. This includes annual CBE for all SMHW women ages 21 to 64 and yearly or every other year screening mammograms for women ages 40 and older. (Refer to Table 1, page 4.6)
  • Family history of breast cancer does not qualify a woman for routine mammograms.
  • A client with self-reporting abnormal breast self-exam (BSE) may be followed with a diagnostic breast work-up, except for self-reporting pain and tenderness or family history. If pain and tenderness are self-reported, she may be followed with a rescreening CBE in two (2) weeks up to 10 months. If the client continues to report pain and tenderness, case management is at the clinician’s discretion.
  • (Diagnostic workup may include services such as diagnostic mammogram, ultrasound, specialist consult and breast biopsy.)
  • Mammogram funding to screen women 40 to 49 years of age without abnormal breast findings through SMHW is available per clinician discretion.
  • Women 21 years of age and older qualify for diagnostic breast services if breast exam findings are abnormal.

Magnetic Resonance Imaging (MRI)

  • ALL SCREENING MRIs MUST HAVE PRIOR AUTHORIZATION from the SMHW program manager. Contact your RPC with client information for approval from the manager.
  • SMHW will pay for a screening breast MRI to alternate with a screening mammogram and documentation of one of the following:
    • BRCA mutation
    • A first-degree relative who is a BRCA carrier
    • A lifetime risk of 20–25% or greater as defined by risk assessment models such as BRCAPro, Tyrer-Cuzick or the Gail Model (as they are highly dependent on family history)
  • The CDC suggests providers discuss risk factors with all clients to determine if they are at high risk for breast cancer
  • MRI should NEVER be done alone as a breast cancer screening tool
  • Breast MRI cannot be reimbursed to assess the extent of disease in clients who have already been diagnosed with breast cancer
  • To be most effective, it is critical to complete MRIs at facilities equipped with breast MRI equipment and perform MRI-guided breast biopsies
Healthcare professional performing a mammogram on a patient.
Annual Breast Recommendations for Women
AgeRecommendation
Age 21 to 39Complete breast exam by health care provider annually
Age 40 to 49Complete breast exam by health care provider annually
Screening mammogram every 1 to 2 years per clinician discretion
Age 50 and overComplete breast exam by health care provider annually
Screening mammogram every 1 to 2 years
The Missouri SMHW program follows guidelines of the CDC and NCI. Clinically evaluate and schedule appropriate diagnostic procedures within 60 days, for symptomatic women.

High Risk for Breast Cancer

  • BRCA mutation.
  • A first-degree relative who is a BRCA carrier.
  • A lifetime risk of 20-25% or greater as defined by risk assessment models such as BRCAPRO, Tyrer-Cuzick or the Gail Model as they are highly dependent on family history.

Cervical Cancer Screening

  • Pap test results of “inadequate specimen” are not reimbursable by SMHW.
  • Pap test results initially indicating no endocervical cells should refer to ASCCP guidelines.
  • For women who have a cervix, pap tests will be covered every three (3) years if no human papillomavirus (HPV) done, or screening with a combination of a pap test and HPV testing every five (5) years. See Screening Report Form (pages 10.10-.11).
  • Hysterectomy:
    • SMHW will NOT fund pap testing for women who had a hysterectomy for benign (non-cervical neoplasia) conditions. A woman who has no cervix due to a reason other than cancer may have a pelvic exam to establish that there is no cervix.
    • Follow a woman annually for 10 years (conventional or liquid-based pap tests can be reimbursed) if reason for hysterectomy is unknown or if it was for cervical intraepithelial neoplasia (CIN) CIN 2, CIN 3, adenocarcinoma in situ (AIS) or cervical cancer in situ, which was biopsy-documented.
    • Women who had a hysterectomy for invasive cervical cancer should undergo an annual pap test (conventional or liquid-based) annually; or perform HPV testing or Pap/HPV co-test every three years indefinitely as long as they are in good health.
    • Annual pap test maybe done only for persons who meet specific high-risk guidelines for cervical cancer per CDC and/or SMHW Advisory Board approval.
Annual Cervical Cancer Screening Recommendations for Women*
AgeRecommendation
Age 21 to 64
  • Pelvic exam may be offered annually or with Pap testing schedule
  • Conventional or Liquid-based Pap test every 3 years

Or

  • Combination pap test and human papillomavirus (HPV) test every 5 years
Age 21 and over
AFTER HYSTERECTOMY
  • Pap is NOT covered for those whom have undergone a hysterectomy unless: (Page 4.8 Table 3a and 3b)
  • They have a remaining cervix

Or

  • They had surgery for CIN 2, CIN 3; CIS/AIS (eligible for annual pap or HPV testing or Pap/HPV co-test every three years for 10 years from date of hysterectomy).
  • They have invasive cervical cancer (eligible for annual pap or HPV testing or Pap/HPV co-test every three years)
The Missouri SMHW program follows guidelines of the CDC and American Society for Colposcopy and Cervical Pathology (ASCCP) for screening and diagnostic recommendations.
NOTE: * Intervals above are guidelines for asymptomatic women only. Evaluate and schedule appropriate diagnostic procedures quickly, within 60 days for symptomatic women.

 

Cervical Cancer Risk Factors to Consider

Cervical Cancer Risk Factors to Consider

Women who warrant annual Pap test (conventional or liquid-based) must have a personal history of one of the following HIGH RISK factors:
  • Hysterectomy for invasive cervical cancer. Screenings may continue indefinitely, as long as they are in good health.
  • CIN 2, CIN 3 or CIS/AIS lesions documented by tissue biopsy after hysterectomy (not based on Pap results). Follow routine pap intervals after the client has 10 years of annual pap test or HPV testing or Pap/HPV co-test every three years with negative results.
  • Hysterectomy with reason unknown and not obtainable. Follow routine Pap intervals after the client has 10 years of annual pap test with negative results.
If Pap test is performed for one of the following reasons, please note this in the comments section on the blue screening form.
  • Human immunodeficiency virus positive (HIV+)/Immunocompromised from another health condition
  • Kidney or other organ transplant
  • Medication for severe arthritis or other collagen vascular disease
  • Diethylstilbestrol exposure in utero
Risk factors which are NOT adequate to warrant annual pap screening:
Risk factors which are NOT adequate to warrant annual pap screening:
  • Smoking
  • Low income
  • Numerous sexual partners (known or suspected)
  • HSIL unless histologically diagnosed with a biopsy

Blue Screening Form

All forms are annually associated with their specific grant year. When submitting an electronic or a paper form, use the version of the form that is the grant year, which corresponds with the date of service. At the beginning of each grant year there are multiple versions of this form in MOHSAIC (page 10.10-.11). Be sure to click on the correct version when entering electronic forms. If using paper forms, check for the year of the form in the lower left corner: example (3/14).

NOTE: The Screening Report Form, also referred to as blue screening form, must be completed for all clients participating in the SMHW program. Please order blank forms from SMHW by calling 573-522-2845 or toll-free at 866-726-9926.
  • Information from the blue screening form is used to verify clients’ eligibility for screening, as well as diagnostic services that are recommended. Some information from the blue form is reported to the CDC. Keep all information confidential.
  • The information on the original form shall be entered electronically in the MOHSAIC system. File all reported information in the client’s record.
  • Access MOHSAIC electronic forms at this link.
  • A copy of the blue screening form is located on pages 10.10-.11 or download a copy here.
  • If you have additional questions, please call SMHW toll-free 866-726-9926 or 573-522-2845 for general assistance with central office staff.
  • If you have questions or concerns regarding specific issues with MOHSAIC, contact the ITSD Help Desk by telephone at 800-347-0887 or by e-mail at support@health.mo.gov.

SMHW Clinical Service Summary

Provider ServiceSMHW Client

Initial and Annual Screening:

SMHW 20-minute office visit

SMHW Client:

  1. Provide verification of household income, date of birth
  2. Sign eligibility agreement form to participate in SMHW/WISEWOMAN services
  3. Complete green history form (pages 10.8-.9)

SMHW Provider:

  1. Verify client eligibility and retains a copy of the documentation in the chart
  2. Give a copy of HIPAA form to client
  3. Review client history form with client; update or clarify information on subsequent annual visits
  4. Perform CBE on women age 21 to 64 or older
  5. Refer clients 40 years and older whose CBE is normal or benign for screening mammogram at one to two year intervals (Refer to Table 1, page 4.6)
  6. Perform pelvic exam on all women ages 21 to 49. Offer pelvic exam to women ages 50 to 64 or older
  7. Perform pap tests per SMHW/CDC protocols and intervals depending on age, previous screening cycle, presence of cervix, reason for hysterectomy, and previous pap result (page 4.7, Table 2 and 4.8 Table 3 guidelines)
  8. Schedule follow-up as needed. Refer clients with abnormal breast and cervical results for diagnostic exams as needed
  9. Submit green history form and blue screening form
Tobacco Quitline:

SMHW Provider:

  1. Refer clients who smoke to the Missouri Tobacco Quitline, 800-QUIT-NOW (800-784-8669)
  2. Provide Quitline card

Diagnostic Office Visit:

20- or 30-minute office visit. 
*Specific timeframes may apply.

SMHW Referrals/Diagnostics:

  1. Follow abnormal breast results within 60 days of result
  2. Follow abnormal cervical results by diagnostic tests within 60 days
  3. Refer women age 21 to 64 or older who have abnormal CBE, qualifying self-reporting symptoms, or personal history of breast cancer for diagnostic mammogram and possibly other breast diagnostics
  4. Schedule client for cervical follow-up rescreens or further cervical diagnostic services as needed
  5. For alert/abnormal screening results, complete documentation of scheduled or completed medical evaluation and results on appropriate sections of the blue screening form
  6. Electronically submit purple breast form and yellow cervical form
  7. Contact RPC for any client refusals or patterns of missed appointments

Table of Contents

On this page