Mount Carmel Health Partners HEDIS Tip Sheets - Page 8

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. 8