Mount Carmel Health Partners HEDIS Tip Sheets | Page 12

HEDIS Tip Sheet
Cervical Cancer Screening
Definition: Percentage of women 21–64 years of age who were screened for cervical cancer:
• Women ages 21–64 who had cervical cytology performed every 3 years.
• Women ages 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years.
Service Needed: Cervical cytology between January 1 two years prior to the measurement year and December 31 of
the measurement year. For women ages 35 – 64, cervical cytology and an HPV test performed on the same date
between January 1 four years prior to the measurement year and December 31 of the measurement year.
Exclusions:
• Hysterectomy (total, complete, or radical) with no residual cervix any time during the member’s history through
December 31 of the measurement year.
• Hospice care in the measurement year.
Chart Review Tips:
• Cervical cytology and HPV tests and results are usually listed in the “Lab” section of the chart.
• Review the "History" section of the chart for note of a complete, total, or radical hysterectomy (exclusion). Note
the exclusion for future reference.
• Review chart for indication patient sees Ob-Gyn for annual cervical cancer screening, if so review
"Correspondence" section for results, you may need to outreach to the patient's Ob-Gyn physician.
Member Outreach Tips:
• Ask patients if they have had a (total, complete, or radical) hysterectomy before reminding them they are due.
• If a patient is due to have her cervical cancer screening within the next 1-2 months, call to remind her to schedule
an appointment with her PCP or Ob-Gyn soon.
Supplemental Data Tips
• A cervical cytology date and result must be present for the screening to meet the measure. A note of “inadequate
cells” or “no cervical cells” without a valid result does not meet the measure.
• For those women ages 35 – 64 who have an HPV and a cervical cytology test, ensure the tests were performed on
the SAME DATE and that results are present. A note of “inadequate cells” or “no cervical cells” without a valid
result does not meet the measure.
• In order for the patient to meet the hysterectomy exclusion, her cervix must have been completely removed.
• Screening may be performed by either the patient's PCP or OB/GYN, whomever normally does her PAP or pelvic
exams.
• Avoid cervical biopsy results due to they are diagnostic and not valid for primary cervical cancer screening.
12