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.

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

• Select “Yes” if the CDP: EWC provider performs cervical cancer screening and/or follow-up.
• Select “No” if the provider only performs breast cancer screening.

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

Date of current pelvic exam: Enter the date if a pelvic exam was performed 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.

Rectovaginal exam performed?

• Select “Yes” if a rectovaginal exam was performed. 
• Select “No” if a rectovaginal exam was not performed.

Previous Pap Smear Test(s)?

• Select “Yes” if a previous Pap smear test was done. 
• Select “No” if a previous Pap smear test was not done. 
• Select “Unknown” if it is unknown as to whether the recipient had a previous Pap smear test.

Date of most recent PREVIOUS Pap smear (date box) or date unknown:

• Enter the month and year of the previous Pap smear test using the following format: Month (MM)/ Year (CCYY). If it has been more than five years since her previous Pap smear test, enter a date at least six years before the current year.
• If the month of the previous Pap smear test is not known, enter the year.  The month field will automatically fill “00.”
• If the year of the previous Pap smear test is not known, select "Date Unknown."

One measure of the program’s success is the number of “never or rarely screened” women who receive a cervical cancer screening. “Rarely screened” means five or more years between screenings. To help track the program’s performance, ask if it has been more than five years since her previous Pap smear test and, if so, enter a date at least six years before the current year.

Date of Pap Smear Test: If a Pap smear test was performed, enter the date 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.

• Use the date the Pap smear test was performed, not the date of the results.
• A Pap smear test (initial or follow-up) starts a new screening cycle and is reported using a Cervical Cancer Screen form. (See Adding New Records.)

Specimen Adequacy (Check one)

• Satisfactory for evaluation: Select if the cytology report states that the Pap smear test was satisfactory or adequate.
• Unsatisfactory for evaluation: Select if the cytology report states that the Pap smear test was an unsatisfactory or inadequate specimen (e.g., a specimen with no epithelial cells or excessive blood cells).
  • If specimen is “Unsatisfactory for Evaluation,” select “Other” as the Pap smear result and enter “Unsatisfactory” as the description. 
  • Select Short-Term Follow-up as the Next Step and submit repeat Pap smear test using a new Cervical Cancer Screen form. (See Adding New Records.)

Specimen Type (Check one): Select specimen type to document the type of Pap smear testing kit used to obtain the Pap smear specimen (conventional smear, liquid based, other or unknown).    

Pap Smear Results (Check one): Select the Pap smear result that best corresponds to the reported Pap smear result.

• Negative for intraepithelial lesion or malignancy
• Atypical squamous cells of undetermined significance (ASC-US)
• (*)Atypical squamous cells of undetermined significance, cannot exclude HSIL (ASC-H)
• Low grade squamous intraepithelial lesion (LSIL) encompassing: human papilloma virus/mild dysplasia/cervical intraepithelial neoplasia (CIN I)
• (*)High grade squamous intraepithelial lesion (HSIL) encompassing: moderate and severe dysplasia, carcinoma in situ, CIN II and CIN III
• (*)Squamous cell carcinoma
• (*)Atypical glandular cells (AGC)
• (*)Atypical glandular cells (AGC), favor neoplastic
• (*)Endocervical adenocarcinoma in situ (AIS)
• (*)Adenocarcinoma
• Other (specify)_____________
  • Examples of appropriate entries for “Other” Pap Smear Results are:
    • No endocervical component
    • Endometrial cells (for women older than 40)
    • Unsatisfactory (i.e., specimen adequacy is unsatisfactory for evaluation)

Note: An asterisk (*) indicates Pap smear results that require an Immediate Work-up as the Next Step and submission of Cervical Cancer Diagnostic Procedures, Diagnosis Status and Final Diagnosis using the Cervical Cancer Follow-Up form.

If Pap smear test not performed, why not? (Check one): Select the description that most closely documents the reason why no Pap smear test was performed.

• Not needed: Select this if the recipient had a normal Pap smear test within the last 12 months or per PCP discretion.
• Needed but not performed (includes refused): Select this if the Pap smear test was indicated but was not performed.  The recipient could have refused the Pap smear.
• Done recently, cervical screening and follow-up services paid with non-CDP funds:  Select this if the recipient had a Pap smear test done elsewhere or services were paid with non-CDP funds (e.g., FPACT).

Based on pelvic exam or Pap smear results, the Next Step for this recipient is:
(Select One)

• Recipient should return for routine rescreen:
  • Select this if the Pap smear test and pelvic exam screening was normal.
  • Submit next cervical screening (Pap smear and pelvic exam) using a new Cervical Cancer Screen form by clicking the Add new Cervical Screening record button.
  • Do not submit next cervical screening using a Cervical Cancer Follow-up form.
• Immediate Work-Up:
  • Select this when additional diagnostic procedures are required without delay to rule out cervical cancer.
  • Complete and submit cervical cancer diagnostic procedures, diagnosis status and final diagnosis using a Cervical Cancer Follow-Up form.
• Short-Term Follow-Up:
  • Select this when additional diagnostic procedures/exams are required after a planned delay (e.g., repeat Pap smear test in 3 to 6 months).
  • Submit next procedure(s) using a new Cervical Cancer Screen form by clicking the Add new Cervical Screening record button. (See Adding New Records.)