Close the gap: Cervical cancer screening documentation tips for providers.

What documentation is needed?

Help us ensure your patients receive appropriate preventive care — and that completed screenings and applicable exclusions are accurately reflected in the medical record.

Cervical cancer screening can help identify precancerous changes early, when they are most treatable. As a valued provider partner, you play an important role in helping our members stay up to date with recommended cervical cancer screening.

When a member has completed cervical cancer screening — or has a documented reason that screening is not indicated — complete and accurate documentation is essential to ensure the member's record accurately reflects their care and applicable quality-measure requirements.

Please document the following, when applicable:

• Date of service when the screening was performed.
• Type of screening performed, such as:
  • Cervical cytology (Pap test)
  • High-risk human papillomavirus (HPV) testing
  • Cotesting (Pap test and HPV test)
• Results of the screening, when available.
• Specimen collection date, if different from the date of service.
• Relevant procedure or laboratory information, including the test name or procedure code when available.
• Documentation from another provider or facility if the screening was completed outside your practice.

Document exclusions clearly.

Not every patient requires cervical cancer screening. For a member with a documented exclusion, clear and complete medical record documentation is critical to ensure the patient's record accurately reflects why screening is not indicated.

One important example is a hysterectomy. Documentation stating “total hysterectomy with removal of cervix” provides important information that can help distinguish a patient who may qualify for an exclusion from a patient who has had a hysterectomy but retains a cervix.

A diagnosis code or documentation of a hysterectomy is not sufficient to determine whether cervical cancer screening is indicated.

Please clearly document:

• That hysterectomy was performed.
• The date and type of hysterectomy, when known.
• Whether the cervix was removed or retained.
• The clinical reason for hysterectomy, when relevant.
• Any additional documentation supporting why cervical cancer screening is or is not indicated.

Examples of helpful documentation include:

• “Total hysterectomy performed 6/15/2020; cervix removed.”
• “Hysterectomy performed 6/15/2020; cervix retained.”
• “History of hysterectomy 2020. Operative report reviewed and confirms removal of uterus and cervix.”
• “Supracervical hysterectomy 2020; cervix remains intact.”

If details of the hysterectomy are not available, consider reviewing the operative report, surgical history, or other medical records to confirm whether the cervix was removed. Updating the patient's medical record with this information can help prevent unnecessary outreach for screening while also avoiding inappropriate closure of a care gap.

Help us close the care gap.

If your patient completed cervical cancer screening elsewhere, please obtain the applicable medical record or laboratory documentation and update the patient's record.

Partner with us to improve preventive care.

Thank you for helping our health plan members receive recommended preventive services and for maintaining complete, accurate medical records. Your documentation helps us accurately identify patients who need screening and appropriately close gaps for patients who have already received care or meet an applicable exclusion.