Note: Data must be entered in a timely manner to ensure claim payment. Tabs for screen and follow-up are visible only after the recipient is certified. When a recipient is recertified, data previously entered is cleared from the screening and follow-up forms to allow data entry for the new certification period.

Breast Cancer Screening or Breast Follow-up Performed through Cancer Detection Programs: Every Woman Counts?

• Select “Yes” if the CDP: EWC provider performs breast cancer screening and/or follow-up.
• Select “No” if the provider only performs cervical cancer screening or if the woman is not eligible for these services (i.e., less than 40 years old).

Note: Providers that provide both breast and cervical cancer screening services are expected to submit breast and cervical data. If the provider only performs cervical cancer screening, submit the completed Cervical Screen form first. Then open the Breast Screen form, select “No” and submit the form with the remaining fields blank.

Clinical Breast Exam (CBE)

CURRENT breast symptoms?

• Select “Yes” if the recipient reports any breast symptoms.
• Select “No” if the recipient does not report breast symptoms.
• Select “Unknown” if (1) the woman wasn’t asked; (2) the answer wasn’t recorded; (3) the woman does not know; or (4) the woman refused to answer.
• Examples of breast symptoms include:
  • Discrete mass/lump
  • Non-cyclical breast pain
  • Spontaneous unilateral nipple discharge
  • Skin scaliness
  • Skin dimpling or puckering
  • Skin ulceration
  • Skin inflammation

Date of CURRENT CBE: Enter the date of the current CBE, using the following format: Month (MM)/Day (DD)/Year (CCYY). This date must not be more than 30 days before the recipient’s certification date.

CURRENT Results obtained from a non-CDP program provider: Select this box if the CBE results reported below have been obtained from a non-CDP provider (e.g., an outside provider and/or not paid by CDP: EWC).

CURRENT Clinical Breast Exam Results (Check One): Select the CBE result that corresponds to the reported result of the CBE.

• No breast abnormality: Select if the CBE was performed and the finding was within normal limits.
• Benign breast condition: Select if the CBE revealed a finding not of concern for breast cancer.
• Probably benign breast condition: Select if the CBE revealed a finding that requires a follow-up exam in 3-6 months.
• Abnormality, rule out breast cancer: Select if the CBE revealed a finding that is suspicious for breast cancer and requires an immediate diagnostic procedure, in addition to the initial mammogram, to rule out breast cancer.

Note: For a screening CBE with abnormal results and negative/benign mammogram result, complete and submit breast cancer diagnostic procedure(s), diagnosis status and final diagnosis using the Breast Follow-Up form.

If CBE not performed, why not? (Check One): Select one of the following if a CBE was not performed.

• CBE not needed at this time:
  • Select if the recipient had a normal CBE within the last 12 months or per PCP discretion.
  • Select if the CBE was performed by a non-CDP provider (an outside provider and/or not paid by CDP: EWC).
• CBE needed but not performed (includes refused/other/reason unknown):
  • Select if the recipient is due for a CBE but one was not performed.
  • Select if recipient refused examination or if due to other unknown reasons, the CBE was not performed.

Previous Mammogram

PREVIOUS Mammogram(s)?

• Select “Yes” if the recipient has had one or more previous mammograms.
• Select “No” if the recipient has not had a previous mammogram.
• Select “Unknown” if it is not known if the recipient has had a previous mammogram.

Date of most recent PREVIOUS mammogram:

• Enter the month and year of the recipient’s most recent previous-mammogram, using the following format:
  Month (MM)/Year (CCYY).
• If the month of the previous mammogram is not known, enter the year. The month field will automatically fill “00.”
• If the year of the previous mammogram is not known, select “Date Unknown.”

To demonstrate program success in rescreening, please make every attempt to find the year of the previous mammogram, if one was done.  To obtain the date of the previous mammogram:

• Check the mammogram report. It includes dates of prior mammograms used for comparison.
• Check the chart for copies of old reports.

Mammogram

Date of mammogram: Enter the date of the recipient’s initial mammogram using the following format: Month (MM)/Day (DD)/Year (CCYY). This date must not be more than 30 days before the recipient’s certification date.

Note: The initial mammogram could be a screening or diagnostic mammogram.

Mammography Results (Check one): Select the mammogram result that corresponds to the reported “Final Result” of the initial mammogram (screening or diagnostic).

• Negative (BIRADS 1):  Select if the assessment was negative.
• Benign (BIRADS 2): Select if the assessment was benign.
• Probably benign (BIRADS 3): Select if the assessment was probably benign.  Probably benign findings have a high probability of being benign.  Further clinical evaluation must be completed for a probably benign mammogram.
  • If there is a planned delay between the initial screening and further clinical evaluation:
    • Select Short-term Follow-up as the Next Step.
    • Complete and submit the next procedure(s) using a new Breast Screen form. (See Adding New Records.)
  • If there is an immediate clinical evaluation:
    • Select Immediate Work-up as the Next Step.
    • Complete and submit breast cancer diagnostic procedure(s), diagnosis status and final diagnosis using the Breast Follow-Up form.
• Suspicious abnormality (BIRADS 4): Select if the assessment was suspicious abnormality.  This indicates the findings do not have the characteristic morphology of breast cancer but do have a strong probability of being cancer. 
  • Select Immediate Work-up as the Next Step. 
  • Complete and submit breast cancer diagnostic procedure(s), diagnostic status and final diagnosis using the Breast Follow-Up form.
• Highly suggestive of malignancy (BIRADS 5): Select if the assessment was highly suggestive of malignancy.  These finding(s) have a high probability of being cancer. 
  • Select Immediate Work-up as the Next Step. 
  • Complete and submit breast cancer diagnostic procedure(s), diagnostic status and final diagnosis using the Breast Follow-Up form.
• Assessment incomplete (BIRADS 0): Select if the assessment was incomplete.  This category is reported as requiring additional imaging evaluation and/or review of prior mammograms. No final assessment can be assigned due to incomplete radiologic work-up. 
  • If the radiologist requires additional imaging to make a final assessment, (e.g., additional mammographic views and/or ultrasound), select Immediate Work-up as the Next Step and submit the breast cancer diagnostic procedure(s), diagnostic status and final diagnosis using the Breast Follow-Up form. 
  • If the radiologist is waiting to obtain old films for comparison, wait for the final assessment report and enter the final result of BIRADS 1, 2, 3, 4, or 5.
• Unsatisfactory, radiologist could not read: Select this box if the assessment was unsatisfactory. 
  • Select Short Term Follow-Up as the Next Step. 
  • After the repeat mammogram is completed, submit repeated mammogram using a new Breast Screen form. (See Adding New Records.)

If mammogram not performed, why not? (Check one): Select the description that most closely documents the reason for no mammogram.

• Not needed: Select this if the recipient had a normal mammogram within the last 12 months or per PCP discretion.  This can include a mammogram done elsewhere.
• Needed but not performed (includes refused): Select this if the mammogram was needed but was not performed.  The recipient could have refused the mammogram.

Based on CURRENT CBE, mammogram, or patient’s concerns, the next step for this recipient is: (Check One)

• Recipient should return for routine rescreen:
  • Select this when both the CBE and mammogram are normal/benign. 
  • Submit next breast screening (CBE and mammogram) using a new Breast Screen form by clicking Add new Breast Screening record. (See Adding New Records.)
  • Do not submit next breast screening (CBE and mammogram) using a Breast Follow-Up form.
• IMMEDIATE WORK-UP:
  • Select this when additional diagnostic procedures are required without delay to rule out breast cancer. 
  • Same-day Ultrasound is considered an Immediate Work-Up. 
  • Complete and submit breast cancer diagnostic procedures, diagnosis status and final diagnosis using the Breast Follow-Up form.
• Short-Term Follow-Up:
  • Select this when additional diagnostic procedures/exams are required after 3 to 6 months planned delay but within the next 12 months. 
  • Submit next procedure(s) on a new Breast Screen form by selecting Add new Breast Screening record. (See Adding New Records.)