Provider Manual - Show Me Healthy Women (SMHW)

A mandatory component as a provider of the SMHW program is the responsibility for providing clinical case management of abnormal findings as well as reporting the abnormal findings, and the outcomes to the SMHW program on a timely basis.

The clinician, using current standards of practice and the established SMHW breast cancer screening protocols, determines abnormal findings clinical case management type and frequency.

Provider Assurances

Providers Must Ensure the Following

Suspicious or Abnormal Breast Results

Clients with suspicious or abnormal breast results will receive the necessary case management as determined by the clinician based on current standards of practice for rescreening, diagnosis, and/or appropriate treatment. Clinicians will report data to SMHW. To meet the program requirements, two diagnostic tests must be completed after an abnormal CBE. In the event a second diagnostic test is not completed, include a detailed comment in the comment section of the breast (purple) form as to why a second diagnostic test was not completed.

CDC - 60 days or less from result of suspicious for cancer screening to diagnosis.

Standard - 60 days or less from time of cancer diagnosis to start of treatment.

Determination of Screening Results

Suspicious screening results will be determined as normal or abnormal through short-term rescreen or diagnostic procedures.

• Notify and explain to the client with abnormal findings the need for any additional diagnostic service(s).
• SMHW requires two documented attempts for client follow-up, if needed.
  • Direct telephone communication is the most effective contact.
  • If unable to reach client by telephone, a letter should be sent indicating there is need for additional diagnostic testing or treatment. For legal purposes, providers are encouraged to use a certified letter.
  • If no response is received after the second attempt or the client refuses further diagnostics and/or treatments, notify your RPC.

Pending Abnormal Screening Results

If abnormal screening results are pending for ten (10) months or longer, client eligibility must be re-checked and a new annual screening test must be performed before the initiation of further diagnostic studies. SMHW will only reimburse for additional diagnostic services if the client continues to meet SMHW eligibility guidelines.

• For clients referred to direct billing diagnostic providers (page 9.5), continue to track that the client receives/attends the scheduled appointments.
• For a client diagnosed with cancer, SMHW providers must provide the following information to SMHW:
  • Date treatment started
  • Type of treatment initiated
  • Name of the facility where treatment occurred

Rescreen Protocol

CBE

• For the first occurrence of breast pain and tenderness, SMHW will only reimburse for an office visit for the CBE. SMHW does not reimburse for breast diagnostics for the first occurrence of breast pain/tenderness.
• A rescreen CBE can be performed after 14 days or within 10 months of an initial CBE with the first time reported pain/tenderness. Please see page 5.10, condition number four (4).
• A repeat CBE is an option as a rescreen, performed 14 days to 10 months after a CBE deemed suspicious for cancer and after the performance of appropriate diagnostic test confirms non-cancer diagnosis. If no prior SMHW documentation is submitted, it is acceptable to enter the first occurrence of pain/tenderness in the comments section of MOHSAIC.

Mammogram

• SMHW will pay up to four consecutive probable benign mammograms within two years. The standard recommendation for a probable benign mammogram is four consecutive six-month follow-ups (a complete cycle of two years). However, if during this follow-up cycle the test result is downgraded to a benign finding (Category II), additional follow-up is not required. If the result remains probably benign or upgraded to a higher category, another type of additional diagnostic testing must be performed within 60 days.
• A repeat mammogram is an option within ten (10) months if the previous mammogram reported to SMHW was a “Category 0, Need evaluation or film comparison.” If “Category 0, Need evaluation or film comparison” is the result reported on a mammogram; film comparison, additional mammography, or ultrasound images are needed within 60 days. If possible, providers should not enter this result until the final result is available. However, if “Category 0, Need evaluation or film comparison” is noted on the blue screening form (pages 10.10-.11), providers should complete the film comparison or take additional images within 60 days. The film comparison result should be reported in the Comments section on the purple breast form (pages 10.12-.13) if the blue screening form has already been submitted. Additional imaging would also be reported on the purple breast form (pages 10.12-.13).

New Breast Lump

• For clients who received an annual SMHW screening that was normal, but later notes a new breast lump, SMHW will not cover the cost of the second office visit but will pay for the diagnostic testing if the CBE is abnormal. If the clinician does not find a lump and chooses to complete diagnostic testing as a result of the breast self-examination, SMHW will cover the cost of the diagnostics.

Ultrasound

• Ultrasound may be used as a rescreening tool when a mammogram is not appropriate. Rescreen must be less than ten months from original abnormal ultrasound screening.

Specialist Consultation Guidelines

A SMHW client may be referred for a specialist consultation following abnormal screening and diagnostic test results. Refer clients requiring a specialist consultation to a surgeon, OB/GYN specializing in breast and/or cervical health, or a physician or nurse practitioner who works for a cancer diagnostic or treatment center. Referral to the same screening examiner is not a specialist consult.

Specialist Consultation Reminder

• Retain a copy of the consult in the client’s chart. Do not submit a copy to SMHW.

Diagnostic Services Available

Guidelines for Breast Diagnostic Services

CBE Suspicious for Cancer

• Completely evaluate and appropriately refer women age 21 and older with a clinically suspicious lesion.

Non-palpable Mammography Abnormality

• Mammography results reported by a radiologist with reference to American Cancer Society (ACS) categories “Suspicious abnormality” (Category 4) or “Highly suggestive of malignancy” (Category 5) should be referred to a surgeon.
• “Additional Imaging Pending” (Category 0) should be followed by additional views, comparison of films and/or ultrasound within 60 days. If comparison of previous films is needed, only the final result of the comparison study should be reported. Providers who have already submitted reporting forms with the “Additional Imaging Pending” (Category 0) should enter results on the Breast Diagnosis and Treatment form in the Comments section.

Ultrasound

• Ultrasound may be recommended when the CBE is suspicious for cancer and mammogram is not appropriate.
• Abnormal ultrasound requires additional diagnostic imaging.
• Refer women whose results are Category 4 or Category 5 to the BCCT program with or without a biopsy.

Breast Biopsies:

Fine Needle Aspiration, Core Needle, Stereotactic, Incisional or Excisional

• The BSE, CBE and/or imaging mammogram/ultrasound must be suspicious for cancer and information submitted to SMHW before the program will reimburse for breast biopsies.

3-D Mammography/Tomosynthesis

• SMHW will reimburse for clients who undergo 3-D mammography (Tomosynthesis).

Flowchart - Selecting the Correct Form When Entering a Mammogram

Flowchart

Guidelines for the Management of Breast Self-Exam (BSE) Reported Symptoms

View guidelines

Guidelines for the Management of Clinical Breast Exam (CBE) Results

View guidelines

Guidelines for the Management of a “Suspicious for Cancer” CBE and First Follow-up Test is a Diagnostic Mammogram

View guidelines

Guidelines for the Management of Women Who Have Suspicious for Cancer CBE and First Follow-up Test Is NOT a Mammogram

View guidelines

Diagnostic Breast Follow-up Algorithms

View guidelines

Purple Breast Form

All forms are specific for each grant year. When submitting an electronic or a paper form, use the version of the form that is dated correctly to correspond with the date of service. At the beginning of each grant year there are multiple versions of this form in 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.

• The blue screening form must accompany or precede the purple breast form. A SMHW or a non-SMHW provider must base the diagnostic service on an abnormal screening result.
• Information from the purple breast form is required by CDC and is crucial for statistical reports and studies. All information received is confidential.
• The information on the original form shall be entered electronically in the MOHSAIC system. All reported information shall be filed in the client’s record.
• MOHSAIC electronic forms can be accessed at https://healthapps.dhss.mo.gov/smhw/.
• A copy of the purple breast form is located in Section 10 - Forms or download a copy online.
• If you have additional questions, please call the RPC for the provider area or 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.

Refer to Section 10, Forms Section or follow link to forms.

Alert Value Follow-Up

The MOHSAIC electronic reporting system has been programmed to produce lists of clients and the SMHW providers who reported abnormal, suspicious for cancer results. These lists are forwarded at least weekly to the RPCs. The RPCs check the MOHSAIC reporting system to determine if follow-up is reported timely. If no information is entered into MOHSAIC regarding the necessary follow-up, the RPC will contact the provider to ensure that follow-up has occurred and that it will be reported by the provider; or, if the provider or client is experiencing difficulty in completing the follow-up, the RPC will assist in contacting the client or in finding appropriate resources.

SMHW Providers Shall

• Implement some form of internal tracking and reminder system to ensure that SMHW clients who have abnormal breast test results suspicious for cancer receive further medical evaluation and treatment within 60 days. This assures scheduling follow-up visits and procedures are completed timely. In addition, client attendance for appropriate follow-up needs to be monitored. If there is a missed appointment, reschedule the appointment and assist with removing barriers such as transportation difficulties.
• Implement some form of internal tracking and reminder system to ensure that women who have abnormal cervical test results receive further medical evaluation and treatment within 60 days. This ensures that scheduling follow-up visits and procedures are completed timely. In addition, client attendance for appropriate follow-up needs to be monitored. If there is a missed appointment, reschedule the appointment and assist with removing barriers to care, such as transportation.
• Promptly notify the RPC when a client is referred to BCCT in order to ensure timely and complete follow-up, complete and accurate tracking and documentation as such. Please report additional information to the RPC who can enter the information onto forms as needed, such as treatment of cancers found.
• SMHW requires two documented attempts for client follow-up, if needed.
  • Direct telephone communication is the most effective contact method.
  • If unable to reach client by telephone, a letter should be sent indicating there is need for additional diagnostic testing or treatment. For legal purposes, providers are encouraged to use a certified letter.
  • If no response after the second attempt or the client refuses further diagnostics and/or treatments, notify the RPC.
  • Utilize a tracking system to ensure that clients show up for scheduled visits and receive the appropriate diagnostic or treatment services.
  • If clients do not keep follow-up appointments, implement attempts to reach the client for rescheduling the appointment by telephone or by mail within 30 days.
  • If the client is no longer reachable or attempts to contact the client fail, please inform the RPC for the provider area within 30 days.