BCCCP MBCIS Data Webinar
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Transcript of BCCCP MBCIS Data Webinar
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BCCCP MBCIS Data BCCCP MBCIS Data WebinarWebinar
December 7, 2010
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Featuring
Ann Garvin, MS, CNM EJ Siegl, MA, OCN, RN Susan Harris, Ph. D. Cathy Blaze
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Objectives
1. Describe how to document the different types of screening and diagnostic services delivered to program women based on the exam result and work-up plan.
2. Identify 1 example for each of the three exam types (screening, follow-up, surveillance) that are used in documenting program services in MBCIS.
3. Describe at least two unusual circumstances that require specific documentation and/or notification of nurse consultants for providing program services that deviate from the medical protocol.
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Types of Office Visits
Annual Screening Office Visit Follow-up Office Visit Breast or Cervical Consult Visit
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Annual Screening Office Visit
Purpose: Provide screening services (Clinical Breast Exam (CBE),
Pap test (if indicated), Pelvic Exam) to identify a potential breast or cervical problem
Scheduled > 365 days from date of last screening
Does NOT have to be the same time every year
Dates can be extended by a few months if results are normal from previous screening and caseload constraints prevent the woman from enrolling
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Annual Screening Office Visit cont.
Office Visits (annual and follow-up) are ALWAYS tied to a service: CBE, Follow-up CBE, Pap test, Follow-up Pap Test, Pelvic Exam
Annual screenings are documented as OFFICE Visits (Full or Partial) depending on exams/tests performed.
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Follow-up Office Visits
Purpose: Examine the client with an identified breast or cervical
abnormality post procedure or post imaging exam
Type of visit documented depends on proceduresperformed
Usually coded as partial office visit (follow-up is problem related)
Scheduled when needed (some limitations apply as to # of visits, and type of monitoring required)
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Breast or Cervical Consults
Purpose: Examine the client with a NEW breast or cervical
abnormality based on screening test results to determine appropriate diagnostic testing OR
Examine a client post procedure for possible complications
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Documenting Office Visits in MBCIS
Annual/Follow-up Office Visits:
Partial Office Visit (OV) – CBE OR Pap and/or Pelvic (one body part examined)
Full OV – CBE AND Pap and/or Pelvic (both breast and cervical (2) body parts examined)
Follow-up Office Visit – entered as either a partial or full office visit following the rules above
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Documenting Consults in MBCIS
Breast/Cervical Consults:
Billing: Consults CANNOT be billed!! Clinical: If client referred for consult; document the
appropriate consult (BREAST or CERVICAL) in MBCIS Consultations are for data entry only, these codes are no
longer approved BCCCP codes
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Data Data Documentation in MBCIS in MBCIS
Basic Data Entry Issues
Opening/closing cycles based on visit type
Enrollment dates
Referral dates
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Basic Data Entry Issues
No extra spaces, hyphens, or other special characters in any of the data entry text boxes (i.e. Names, Comments, etc.)
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Opening/Closing Cycles Based on Visit Type Open ‘initial’ cycle for new clients (never
screened in program previously) Open ‘anniversary’ cycle for clients returning for
annual screening Open ‘anniversary’ cycle for clients returning for
follow up of new abnormality prior to annual screening
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Enrollment Dates
Date the client was enrolled or re-enrolled in the program (i.e. date eligibility information obtained or date woman completed enrollment paperwork)
It does not need to match the first date of service This date can be the same as or before the
client’s first screening service date The enrollment date cannot be after the first date
of service
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Referral Dates Date a client was referred by a non-BCCCP provider to the
program; OR Date that client was first seen by the program To ensure timeliness of care, date of non BCCCP service should not
be used as the referral date Document the referral date on the service summary screen
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Exam Types Types
Screening Follow-up/Diagnostic Surveillance
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Screening Exams
Performed ONCE yearly – NEW CYCLE always opened for screening exams
Are NOT a follow-up exam that is monitoring a previously identified abnormality
Includes the following EXAM types: CBE, Mammogram-Screening (OR Diagnostic-depending on history) Pap test, Pelvic Exam
Office Visit Type: Full (CBE and Pap/Pelvic) or Partial (CBE OR Pap/Pelvic)
CAD is not a payable procedure
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Follow-up Clinical Exams
Clinical Exam Types: Follow-up Pap Tests performed > 6 months post
screening Pap test or post cervical biopsy Follow-up CBE - performed > 2 months from screening
CBE Follow-up exams are linked with PARTIAL Office Visits
(unless both breast and cervical body parts are examined)
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Follow-up Diagnostic Exams cont. Diagnostic MammogramsA “True” Diagnostic Mammogram is performed: Post screening mammogram result of ACR 0 -
Additional Work-up Required
6 months post ACR 3 - Probably Benign Immediately Post breast biopsy to evaluate clip or wire
placement > 2 months post breast biopsy to evaluate status of
abnormality
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Other Diagnostic Exams
Include the following BCCCP reimbursed services Ultrasound Colposcopy ANY type of Breast or Cervical Biopsy Post biopsy mammogram/clip placement
Non-BCCCP Reimbursed services MRI’s, Ductograms, etc. Any diagnostic service that determines a final diagnosis
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Surveillance Exams
Two types: Mammogram Surveillance and Pap Surveillance
Used to distinguish abnormal result requiring follow-up
Enter as FIRST exam in a new cycle Surveillance exams are NEVER entered as follow-
up exams in current cycle
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Additional Information
Appropriate funding (Federal, State, Non-BCCCP, Other) based on referral source and exam type Most exams should be coded as Funding ‘Federal’ Screening Mammograms for 40 – 49 yr olds should be coded as
Funding ‘State’ Services provided outside of the program should be coded as
Funding ‘Non-BCCCP’
Repeat exams (Mammograms, Pap Tests) Repeat exams are screening exams that have an initial
unsatisfactory result – the image or labs could not be read properly. The initial exam is coded as unsatisfactory, the second screening exam should be coded as repeat.
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Documenting Follow-up Services Follow-up Services
Follow-up CBE, Follow-up Pap test, Diagnostic Mammogram
Diagnostic LEEP, Diagnostic Cone, Endometrial Biopsy (EMB)
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Documenting Follow-up Exams
Documentation Guidelines Normal/benign results requiring no follow-up or short-term
follow-up
• Document in the SAME cycle as screening exams
Abnormal results requiring immediate follow-up
• Open a NEW cycle in MBCIS
• Code abnormality as Mamm / Pap Surveillance
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Follow-up Pap Test (same for F/U CBE)
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Documenting Follow-up Services: Documenting Follow-up Services: Breast
Breast Biopsy (inclusive category) covers ALL BCCCP reimbursed biopsies
Ultrasound (US) Diagnostic Mammogram New Exam type: Post Biopsy Mammogram/Clip
Placement Appropriate use of “Other Diagnostic Procedure –
Breast: DO NOT USE
For questions re: data entry call State Nurse Consultant (NC)
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Follow-up/Diagnostic Mammogram
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Documenting Follow-up Services: Cervical Biopsy types: ECC (endocervical curettage), cervical
biopsy Appropriate use of “Other Diagnostic Procedure -
Cervical”?: DO NOT USE
Use of subsequent follow-up services: follow-up Pap and/or follow-up colp x1
For questions re: data entry call NC
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Documenting Follow-up Services: Follow-up Services: CervicalCervical
EMB: for AGC Pap result only Not for “endometrial cells present” in woman
>age 40 or any other result
Contact NC with MBCIS# and date of EMB NC will enter into MBCIS
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Documenting Follow-up Services: Cervical Diagnostic LEEP and Diagnostic Cone For Pap results of HSIL or AGC only For colp results of CIN1/ “not
cancer”/atypia/unsatisfactory only CIN2+ receives Medicaid for treatment LEEP/Cone are now TREATMENT
NC enters into MBCIS: contact w/ MBCIS#, date and type of dx procedure
Final dx date: date of dx LEEP or cone
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Documenting Surveillance in MBCISMammogram SurveillanceUsed in the following 4 situations: When a client has an abnormal CBE and is referred
for a mammogram When a client is referred from a non-BCCCP provider
to the program for diagnostic work-up for an abnormal Mammogram
To open a new cycle mid-year because the follow-up Diagnostic mammogram is abnormal and requires additional diagnostic tests
After radiologist issues final ACR result from a film comparison.
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Use of Mammogram SurveillanceAbn STF – additional F/U required
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Use of Mammogram Surveillance: Film Comparison Screening Mammogram result on 12/15/08;
Radiologist wants previous films for comparison. What is the result of the Screening Mammogram in this instance?
Work-up Plan = Short-term
Comparison Film obtained – Radiologist amends final result on 1/28/09 to ACR 2 – Benign Finding
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Use of Mammogram Surveillance: Film Comparison
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Pap Surveillance
Used in the following 3 situations: When a client is referred from a non-BCCCP provider
(E.g. Family Planning Clients) to the program for diagnostic work-up for an abnormal Pap test
To open a new cycle mid-year because the follow-up Pap test is abnormal and requires additional diagnostic tests
To document yearly Pap tests for women with a history of CIN 2-3 (20 years) or hysterectomy for dysplasia or cervical cancer (“forever”)
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Use of Pap Surveillance
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NEW Exam Types
Post biopsy mammogram/clip placement No Result is Required . DO NOT USE “OTHER” for this
exam
Non-Standard Care Used by Nurse Consultants ONLY to document clinical
care that deviates from medical protocol
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Appropriate Coding of Final Diagnosis Data/Date Work-up Complete: finished w/ final dx Refused: if patient refuses to have care
Put in date and “Not Applicable” for dx Lost to Follow-up: can’t find patient
Put in date and “Not Applicable” for dx Work-up Interrupted: dx in process (left country, other health issues)
Put in date and “Not Applicable” for dx Treatment Start Date
Diagnostic LEEP or Cone: “treatment started”, date of LEEP/Cone, type “surgery”
Surgery, Chemo, etc – date of surgery, start of chemo, etc Data Deletion – any deletion on the service summary screen will
delete the diagnosis and treatment data. You will need to re-enter the diagnosis and treatment data!
““NotNotApplicable”Applicable”
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Special Circumstances Multiple Surgical Consults
Multiple tests/procedures pre and post biopsy
Complications post biopsy
Nurse Consultant Approval Exams/ procedures
Non-Standard Care
Documenting No Treatment for CIN 2 Clients < age 30
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Multiple Surgical ConsultsMultiple Surgical Consults Breast consults - Reimburse up to 2 surgical
consults/office visits per year: Pre breast biopsy, and immediately post breast biopsy.
Cervical Consults - Reimburse for consult on DAY of cervical diagnostic procedure.
If cancer diagnosed, will reimburse for post biopsy consult/office visit
Additional breast and cervical consults beyond guideline above require NC approval; reviewed on case by case basis
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Multiple Tests Procedures Imaging Tests Pre and post biopsy
US and US guided biopsy – reimbursed ONLY in select circumstances
Complications post breast biopsy – surgical consults (# dependant on problem) reimbursed to evaluate biopsy induced infection/hematoma
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Nurse Consultant Approval Exams/procedures NC Approval required for:
Diagnostic LEEP, Diagnostic Cone, EMB ANY consult/exam/procedure reimbursed by BCCCP
that deviates from medical protocol
Non-Standard Care -- ANY consult/exam/procedure NOT reimbursed by BCCCP that deviates from medical protocol BUT impacts FINAL diagnosis
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Documenting No Treatment for CIN 2 Clients < age 30 If plan is follow with colp/Pap at 6 months
Put in “treatment, not needed” and put in comments “Pap/colp in 6 months”
After 1st follow-up Pap/colp, if still NO treatment planned, patient returns to care of Family Planning for surveillance (no data in MBCIS)
If situation changes (now CIN3/CIS and/or treatment), BCCCP will provide care
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Questions!
Ann Garvin MS, CNM 517-335-9087 [email protected]
Susan Harris, PH. D. 517-324-7306 [email protected]
E.J. Siegl MA, OCN, RN 517-335-8814 [email protected]
Cathy Blaze 517-241-0109 [email protected]