The Evolving Well Woman Visit (4-26-18)

The Evolving Well Woman Visit (4-26-18)


– [Instructor] Examinations and basically, who has written the
guidelines for those exams and then we’re gonna focus
on three particular areas of debate and sort of evolution in terms of the kind of things that we do in the well woman visit. So with that, let me start by saying that I don’t have any relevant disclosures to make about any sorts
of commercial interests. And before you, you have
the learning objectives for our webinar this afternoon. I’m gonna start with a case study, and we will discuss Marisella, both in terms of her medical history, the kinds of screening
tests that she might need at her well woman visit
and then near the end of the webinar, we’ll also talk about how to code her visit as well. So Marisella is a 28-year-old
gravata two para zero, abortion two, established client, which means that she’s been seen in our clinic in the last three years, who now comes in for a well woman visit. She’s been in a monogamous relationship for the past two years. She’s feeling well and has no complaint of a vaginal discharge,
abnormal vaginal bleeding, or painful intercourse. Her last cervical
cytology was two years ago in another city. And she’s currently using
oral contraceptives. We’d like to continue to use OCs and request a year’s supply. So we’ll start with a couple of questions. First one is, which screening test does the US Preventative Services Task Force recommend for Marisella and second is, what do you think the single
most important question is to ask her in regard to
her well woman visit based on the information that I’ve given you or for that matter have not given you so far? So the first thing is is that these are the
potential screening tests that might be offered to
Marisella given her age. And I want you to think about two things. Number one is if you are
the clinician taking care of Marisella, which of
these tests would you order? And the second is to go back
to my original question, which was which of these
tests would be indicated for Marisella given the history that I provided to you so far? The answer is actually only a single test, and that’s an HIV-1 serology. And so for the remainder of the webinar, we’ll be talking about the
reasons that you would do that test in Marisella’s situation but that you would not be doing any of the other tests that are on the list. Now from my point of view,
the most important question to ask that I haven’t
really told you the answer to already, is to be sure to ask Marisella about whether or not she already has
a primary care provider. The part about the
women’s health provider is if you are acting as a
primary care provider, you’d ask her, are you also a patient in a family planning clinic
or do you see an obstetrician, gynecologist, or a nurse,
midwife, for example. So if Marisella said that she
had a primary care provider, what I’d ask is when did you see her, or it might be a him. And when you did see your
primary care provider, which tests were performed for you? When were they performed? And do you know the results? That’s critically important
because of the fact that eight years ago, as the result of the Affordable Care Act, many, many more women than in the past now have
either first count Medicare or commercial insurance. Even though they’re coming to see us as family planning providers. And we need to know whether or not they’re also getting primary care and screening services
from another provider, most specifically a primary care provider. Right? So we wanna tailor the content of today’s visit in deciding, does she not have a primary care provider? In which case, she may need a more
comprehensive well woman visit. Or because some of these
tests have been done already by her primary care
provider or her clinic, this is going to be much more focused on her family planning. Other things that are very important is that we wanna make sure
that she gets the services that have not yet been performed, but we don’t wanna duplicate things that she’s already received as a way of trying to minimize
any sort of fragmentation of care that she might have by going to two different providers. Now let’s talk a little bit more about how the well woman visit developed and what the various guidelines say about the content of well woman visits. First off, check-up examinations
have been recommended in the United States since the 1920s, and they’ve gone through a
number of different names. Sometimes they’re referred to
as an annual physical exam, or an annual visit. Sometimes they’re referred
to as a check-up visit. But at least in terms of the literature and national guidelines,
those are considered to be out-of-date terms. And the visits that we’ll be talking about this afternoon, the US Preventative Services
Task Force refers to as periodic health screening visits. CPT coding book refers to them as preventative medicine visits. ACOG, for many years, has referred to these as well woman visits, abbreviated to WWV. And that’s what I’ll be focusing on this afternoon is using
the term well woman visit for periodic health
screening visits for women of reproductive age. Now there are a number of objectives for women coming in for well woman visits, the most important of which
are anticipatory guidance, to be able to talk with her not only about her medical history but whether or not she’s engaged in any risky behavior and if so, helping her to
avoid those risky behaviors. The second is to screen for
asymptomatic conditions. Going all the way back to when they recommended
check-up visits in the 1920s, it was based on the idea that
people might have symptoms or signs of diseases that, to them, were not significant enough
to come in to be evaluated. And so one of the main purposes that we ask otherwise, healthy, and asymptomatic women to come in for their well woman visit is to evaluate them for
asymptomatic conditions. And we do that, primarily,
through screening tests. We also know that for people who come in for periodic health screening visits, that if they’re told
that everything is okay, they have a sense of wellbeing and satisfaction. If you’re able to see the same clients or patient over the years,
you might develop more of a relationship with them
because you see them more often. There is also some doubt which says that people who come
in for check-up visits and, particularly, if they’re told that everything is okay where they’re just anticipatory guidance that they’re more likely to take action toward maintaining their good health. In a family planning context,
we have a more specific focus to make sure that the patient is happy with her method and if not, to be able to discuss with her a
variety of other methods that are available to her
to check her understanding of the correct and the consistent use of the method that she’s chosen for family planning as well as clarifying her reproductive intentions and doing other interventions to optimize her reproductive health. Now in some ways, it would be helpful if there were a single national guideline that defined one specific manual of well woman services. But unfortunately, we have to deal with guidelines coming from a number of different places. However, the good news is is
that they are mostly very close to each other. There are not very many divergences. In a few minutes, we’ll be talking about where some of
those divergences exist. Probably the mother of all
prevention services guidelines in the United States are produced by the US Preventative Services Taskforce. And most primary care specialty societies, for example, the American
College of Physicians, which are the integral medicine docs, the American Academy of Family Physicians and others have simply adopted the US Preventative Services
Taskforce guidelines as their own. Most commercial health plans use these as well. ACOG has a similar but
slightly different set of guidelines for the well woman visits, which are called primary and preventive care guidelines. The American Cancer Society
has screening guidelines for various types of cancer
that I’ll be referring to today. The Federal Title X program operated from the Office of Population
Affairs about working with the CDC developed
a group of guidelines that include well woman visits. After all the QFPs, Providing Quality Federal
Posterity Services. And the Affordable Care
Act itself has a whole menu of women’s preventive services that need to be available to women without any cost-sharing. And that’s not an issue
in family practice, of course, but for women
who do have either medical or who have commercial insurance, they have to receive certain services that are either A or B recommendations from US Preventative Services Taskforce or locate additional
services that were added by the CNS. Now one of the things that I’ll also be listing
here is the recommendations that the US Preventative
Services Taskforce use in terms of explaining how good the evidence is that we should be either routinely or more selectively doing a
procedural screening test. So to the degree that a
screening test has an A or a B recommendation, that’s one that we should be offering to most people. A C means that in a population of people, the benefits and the harms of a particular screening test are about an equal balance. So in that circumstance, we have to make a decision, if you’re
decision making with a patient about whether or not that
particular test will be right for her. We’ll also talk about some Ds and Is. A D is when a particular
test has no benefit or when the harms outweigh the benefits. In that circumstance, we
should abandon the use of the test and not do it routinely. And finally, we’ll look at one or two Is, which means that
there’s just not enough evidence for the US Taskforce to be able to make a decision. Now when you look at the ACOG
well woman recommendation, and we’ve included a
link to their website, you’ll see that it’s broken
into different age groups. So Marisella fits into
that age group category of 19-39 where ACOG will
give us their recommendation for that screening intervention. Laboratory tests,
evaluation and counseling, and immunizations for a woman in that age group as well. But some questions that come up commonly about well woman visits is, first off, is the physical examination necessary with every well woman visit? The answer is is that you only need to examine particular areas of the body as needed for scheduled screening tests. So, for example, if a
person like Marisella, who’s 28, is receiving
her cervical cytologies or pap smears every three years, then, of course, we’d have
to put in a special exam to do that pap smear
on a three-year basis. Then, of course, a person might come in for a well woman visit
and have other complaints, pelvic stinging, irregular bleeding, vaginal discharge, dis-fur-mee-a. Under that circumstance, she would need a physical assessment. Not as a screening physical exam but as a diagnostic exam
when symptoms are assigned for present. Now it is important for us to realize that for many women who come in for a well woman visit, that
that will primarily be a visit that’s involved in
counseling and education and without any need for
a physical assessment beyond a blood pressure check as long as she’s not in for a pap smear or if she has no specific signs or symptoms or complaints that need to be evaluated. The next question is do
these well woman visits need to be done every year? The answer is that all
the things are the US. The US Preventative
Services Taskforce says that a well woman visit
should be done every one to three years depending
on the health status and the risk behaviors of the client. Meaning that if a woman is very healthy, have few or no risky
behaviors, no chronic diseases, every two or three years is probably fine for her. On the other hand, if it’s a person who has risky behaviors, chronic diseases, or just needs reassurance more often, then having a well woman
visit every year is equally acceptable. ACOG, on the other hand, still recommends that well woman visits
be performed annually. Now I mentioned this guideline earlier. So I think it’s important for anybody to do family planning services. It’s called the Providing Quality Family
Planning guidelines, abbreviated as the QFP. And it’s intended to be a companion to the CDC medical eligibility criteria, which has to do with the safety of using various contraceptives as well as the selective
practice recommendations from the CDC that are guidelines about how to help women
effectively use contraception. What the QFP does is it sort of fills in the gaps in what the other CDC, family planning guidelines don’t do. So they can plan today’s sections on pregnancy testing counseling, helping women to achieve pregnancy, and managing basic infertility. Preconceptions here and then
preventive health screenings of both women and men as well
as a really helpful section on contraceptive pamphlet. So this is yet another
source of guidelines on well woman visits. But what the QFP says is that, given the fact that we
only have a limited time with each patient, typically 15 or 20 minutes if you’re seeing three or four patients an hour,
that there are some things that are considered in the
core family planning services that need to be done at the time of a well woman visit. They include a discussion
of reproductive life plan, helping a person, of
course, make a decision about which method she’d like to use and then advising her about
the safe and protective use of that contraception, assuming that she wants to avoid pregnancy for now. Screening for reproductive coercion, or birth control sabotage,
asking about sexual behaviors and also sexually
transmitted risk screening, asking her about alcohol, tobacco, and drug use, and also asking
at least screening questions about her family history of breast and ovarian cancer. Now those are considered to be mandatory for any family planning
either initial visits or follow-up of a well woman visit or periodic health screening visit. The second level in the QFP guidelines are
the cancer screening tests that we’ll do, and we’ll
talk more about those in just a moment. Then they have the third level of visits, which are called
other preventive services. These are all things that are important for a woman’s health status both now and going forward, but they really don’t have
any direct relationship to the core of family planning services. So there are things like
talking about a healthy diet or have you seen your dentist or things that you can do to prevent injury or how to stop smoking or visits to a drug treatment program
or having vaccinations for things that are not directly related to reproduction or, for that matter, even screening for other kinds of cancers, which are not related to reproduction. And basically, the way that the QFP looks at these is that, if we have time after we’ve covered the core
family planning services, that these are things
that can all be addressed, that they really fall more into the vein of primary care and are secondary for us to do within the context of a family planning visit. Even if a patient doesn’t
have a primary care provider, even if we’d like to be able to do these. The other family planning topics that I just mentioned really have priority when we only have a limited amount of time with each patient. So let’s go back to Marisella and talk about the kinds of tests that she needs. So first, does she need any sexually
transmitted infection screening tests? This table physically refers
to various screening tests for different types of
sexually transmitted infections in different age groups. There’s noting that Marisella is 28 and in a mutually monogamous relationship. So that being the case, she
really doesn’t meet the criteria for targeted screening for gonorrhea and chlamydia. She doesn’t have any of the risk behaviors that would tell us that she needs to be screened for GC and CT. The next possibility, though, is HIV, and we have no evidence
based on the history that I gave you that
Marisella has ever been tested for HIV. So that would be an
important screening test for her, given the recommendations from the CDC, the US Taskforce, ACOG, and others, about a
once-in-a-lifetime HIV test even for low-risk individuals. Finally, for syphilis,
vaginal trichomoniasis, Hepatitis C, none of
those would be appropriate in her tests given the history that I gave you a few minutes ago. I’m going to very quickly remind you about what the guidelines do say about routine screening for chlamydia and gonorrhea. I’ll tell you about two
important guidelines. One is the US Preventative
Services Taskforce guidelines that I mentioned at the beginning and number two is guidelines from our own California
Department of Public Health. I actually think that the CDPH guidelines
are a little more specific, and that makes them a little better. So when it comes to routine screening for gonorrhea and chlamydia,
the US Taskforce says that we should be screening all
sexually active non-pregnant women who are 24 years
of age or less annually, older women who are at
increased risk, and for men, they make no recommendation
about routine screening for gonorrhea and chlamydia. The California STD Control Branch adds to that. If your practice-site specific prevalence of gonorrhea or chlamydia is elevated, then you might screen everyone in your practice. And the cutoff bar is
that the chlamydia rate in your practice is three percent or more or if the gonorrhea rate in your practice is one percent or more that you should be
doing a routine screening for gonorrhea and chlamydia. Now an obvious question is how do you find out what the rate of gonorrhea and chlamydia is in your own practice? And the answer is is that someone from your practice can get in touch with the laboratory that you use, and they can request or tell us about our rate of positivity for gonorrhea and chlamydia over the last year or two. You can even break that down
by individual age groups. The best way to do that
is by your age groups. And when you have an age group of, let’s say, women who are 26 to 30 who have rates of chlamydia
higher than three percent or gonorrhea higher than one percent, the these are groups of people who should be screened routinely. Now the US Preventative
Services Taskforce goes on to define high risk or increased risk for gonorrhea and chlamydia as women who have had a previous or
who have a concurrent STI, new or multiple sexual partners, a sex partner who has other partners, a sex partner who has a
sexually transmitted infection, inconsistent condom use among people who are not in a mutually
monogamous relationship, and those who exchange sex for money or drugs. The problem is that I don’t find those
guidelines very helpful in regards to defining. New or multiple partners
over what time period for example? And that’s, I think,
one of the real values of the guidelines that were published by the California Department of Public Health a few years ago. When they say a gonorrhea
and chlamydia screening in women 25 years of age and older and when the practice-site
specific prevalence of gonorrhea and chlamydia
in your practice is low, chlamydia is less than three percent, gonorrhea is less than one percent. Basically, you need to look at four things in deciding who needs to be screened. Does the woman have a
history of gonorrhea, chlamydia, or PID within
the last two years? Has she had more than one sexual partner in the last 12 months? Has she had a new sexual
partner in the last 90 days or does she have reason to believe that her partner is having sex with other people in the last year? If not, the question is, is
it theoretically possible that your partner’s having
sex with someone else or do you think that
your partner’s having sex with someone else? It turns out that
there’s a low correlation with chlamydia or gonorrhea positivity if you ask the questions in those ways. If you ask, do you have reason to believe that a sex partner, that your sex partner
has had other partners in the last year that is correlated with a higher likelihood
of being gonorrhea or chlamydia positive. So this is a very simple
way to ask four questions for women who are 25 and older about whether or not they need to be screened for
gonorrhea and chlamydia. And in Marisella’s case, she answered no to all those questions, and therefore, she doesn’t need to be screened for either. Now what she does need to be screened for is for HIV because, as I mentioned, ACOG and the US Preventative
Services Taskforce recommend that both men and women who are between 15 and 65 years of age be screened for HIV at least once in their lifetime. And then, subsequently,
they should be re-screened at least once a year based on a variety of risk factors. So injection drug users, sex partners of injection-drug users, and so on down the list. I would answer that that if Marisella, if the pregnancies that she’s had, if she was tested for HIV in the course of receiving prenatal care, for example, and her HIV test is negative, that counts as her once-in-a-lifetime HIV test. But we learned from Marisella that she, given the fact that she’s not been in prenatal care, she’s
not had a term pregnancy, she’s never had an HIV
test, and therefore, she does meet the criteria for this once-in-a-lifetime
HIV test even in a low risk individual. The US councilor says
that only those persons who are at increased risk of
syphilis should be screened for syphilis. That’s men having sex with men, who account for two-thirds
of syphilis diagnoses, men and women living with HIV, the history of incarceration
or commercial sex work, certain racial and ethnic groups, disappeared there for a moment, African Americans have higher rates of syphilis than Hispanics, which in turn, are higher than whites, and
being a male less than 29 years of age. Probably most importantly is living in an area with what’s called a hotspot. So if you’ve been informed by your local county health department that you are practicing in
an area that’s considered to be a hotspot for syphilis,
then chances are good that most of your patients,
if not all of them, will be screened for syphilis. But if you’re not in a hotspot and your patient does
not meet these criteria, then it’s not necessary to screen for syphilis. Now let’s switch over
to metabolic screening. Is there anything that
Marisella needs given the fact that she wants to continue
using birth control pills? So in her age group,
again, remember she’s 28, recommendations state that she should have
a blood pressure check at least every two years as well as having her body mass index calculated. Remember, that’s a
combination of her height and weight. But basically, according to guidelines, that’s really all that needs to be done. Depending on whose guidelines you look at, it’s screening for Type 2 diabetes or for checking lipids. Basically, she, based on the history that I gave you, is not a candidate for either diabetes testing
or hyperlipidemia testing. But half the time, at
her well woman visit, you would want to check her blood pressure and also calculate her BMI. Now are there any special tests that need to be done relative to the fact that she wants to use oral contraceptives. She’s been using them successfully. She’d like to be able to continue. And here, we’re gonna
look at a CDC guideline that I hope you’re using called the US Selective Practice Recommendation. And this has a list of the tests that should be done based on what method of contraception a woman chooses to use. So given the fact that
she is a successful user of oral contraceptives, the
CDC guidelines recommend that we should check her blood pressure and her BMI, but there’s no reason to check anything else on the list that has to do with her choice
of using oral contraceptives. So no reason for a bi-annual pelvic exam, clinical breast exam, evaluation of glucose, lipids, liver enzymes, and so on, that have any linkage to safe use of oral contraceptives. All right. So that’s what we’re gonna offer to Marisella. The next question is is
where are those areas that I mentioned earlier in the context of well woman visits? Which are quite controversial at this time and where there’s sort of a moving target of what we might do and where we’re going in terms of the content of the things that we discuss with women or the tests that we perform at the time
of their well woman visit. Then we’re gonna focus on four areas, reproductive goals counseling, cervical cancer screening,
whether or not it’s necessary to do a screening clinical breast exam, and a screening pelvic exam. First off, let’s start with
what I mentioned earlier in the CDC OPA guidelines
where they recommended that the time of a well woman visit, we should discuss her
reproductive life plan. That term has been used since
the CDC published guidelines about free conception care in 2006 so it’s been at least a decade that we have discussed this concept of a reproductive life plan, and there have been various
recommendations about how that actually be implemented
as we do patient care. The thing is that this
has been evolving based on the fact that the term
plan doesn’t really resonate with some women because of cultural or religious or just economic reasons. And I’ll tell you more about that in just a moment. Now reproductive life plan
questions have been evaluated or defined in a lot of different ways. Originally, in the CDC free
conception care guidelines, it was a fairly long list of questions. For example, do you hope to have children or if you have children now, do you hope to have more children? What is your ideal family size? How many children do you hope to have? How long do you plan to wait
until you become pregnant? How much space would you like
between your pregnancies? What do you plan to do until you’re ready to become pregnant in terms
of your family planning method and what can I do today to
help you achieve your plan? These are fairly long versions of the questions that needed to be asked. The other end of the
spectrum is best exemplified by a program that was pioneered in the state of Oregon well over a decade ago called One Key Question. This was really more focused on primary care providers
than it was on us as reproductive healthcare providers but what the recommendation
was that when a woman came to her primary care provider
for her well woman visit, that the most important
question to ask relative to her reproductive
plans is would you like to become pregnant in the next year? They actually looked
at many different ways of asking that question, they found that that was the one that people were most
comfortable answering. And they also came up with guidelines that were fairly binary like yes, I would like to become pregnant in the next year, at which time you get free
conception counseling and maybe some counseling
about how to become pregnant and so on. Or if a woman said, no, I
don’t wanna become pregnant in the next year, that that
would direct a whole period of interventions that have to do with family planning. The thing is is that we’ve come to realize that pregnancy
intentions are not binary. They’re not, yes, I wanna get pregnant or no, I don’t. They’re much more complicated than that and what’s now being referred to as a multidimensional concept. And that is what plans, or the decisions about when to become pregnant, is actually the formulation
of an action plan. That’s a little different than intentions. It’s timing-based ideas about if and when to become pregnant or can include wants without actual plans. Then another level is a person’s feelings or their emotional orientation toward pregnancy. And then their desires, which has to do with the strength of
their inclination either to get pregnant or to avoid pregnancy. So it’s important to realize that, as we’re asking about
pregnancy intentions, we understand that plans and intentions and desires and feelings
are all different concepts, and some women may find
all of them meaningful but others may only find certain ones of the possibilities meaningful to them. And what is difficult for us as clinicians to understand sometimes is that they often appear
inconsistent with each other. Now what do I mean by that? This is a really helpful
way of kind of looking at pregnancy intentions beyond
this sort of binary yes, I wanna become pregnant or no, I don’t. So on the x axis on the bottom is how strongly a woman
feels about her desire to avoid pregnancy. On the y axis, it has to do with how strongly she feels about
actually becoming pregnant. So if a woman feels very strongly that I wanna become pregnant! I have no intention of avoiding pregnancy. Then that’s what is referred
to as a pro-natal response. On the other hand, if a
woman says I have no desire at all to become pregnant, and
I will do everything I need to to avoid pregnancy, that’s referred to as an anti-natal response. Those are the sort of
two ends of the spectrum. The binary approach I
mentioned a moment ago. Either I wanna be pregnant
or I don’t wanna be pregnant. But there are two other categories. One is when a woman has
relatively low desire to become pregnant, but she
also has a relatively low desire to avoid pregnancy. It’s what’s referred to as
an indifferent attitude. Like, yeah, I can live
with getting pregnant. I don’t particularly want to but if I get pregnant, that’s okay. And then the fourth one
is what’s considered to be an ambivalent attitude. I very strongly don’t
wanna become pregnant but on the other hand,
there’s another part of me that really loves the idea of being pregnant right now. So there’s no indifference here. There are very strong emotions and feelings. And part of me wants to be pregnant, and another part of me
does not wanna be pregnant, and that’s referred to as ambivalence. So the interesting thing
about One Key Question is that it has evolved over
time from a binary answer of yes or no. Would you like to become pregnant in the next year? To one that’s a little more nuanced. Yes, no, or I’m not so sure. Number one being ambivalent
or it’s okay either way. And, basically, now there
are four different algorithms that help us, as clinicians,
to advise women based on the answers they give. If they say yes, we can help
with free conception care and ideas about how to get pregnant. If no, then we’ll talk with them about their plans for
preventing pregnancy. But for women who are okay either way or more or less indifferent, the ones who aren’t sure or unsure is a part of me wants to get pregnant, a part of me doesn’t. And by the way, on the
One Key Question website, they provide algorithms for each of the four different pathways. So one last thing I’d like to mention is that another approach is
becoming fairly widespread, and I think this is really nicely done. Published in an article by Lisa Callegari and a number of other investigators. I mean, they’re in
general OB/GYN last year. And it’s called the PATH questions. P-A-T-H, which means Pregnancy Attitudes, Timing, and How Important
is Pregnancy Prevention. So instead of the things that I mentioned to you a moment ago about, you know, these various either short-term or single question approaches
that we might take. Basically, you have three questions. The first is do you think you might like to have children at some point? Or if you already have children, would you like to have more children at some point? Then the next question is if she says yes, when do you think that might be? And would you like to become pregnant in the next 12 months? Then the third question
in the PATH approach is how important is it to
you to prevent pregnancy until then? And that gives you some
idea about her result to prevent pregnancy or not. So, again, sort of the shortcut to getting at what her
pregnancy intentions are without using the word plan in a way that’s been shield tested and
seems to be quite successful as a way of evaluating
pregnancy intentions. Now let’s go to the next
of the controversies, which is around the area of
cervical cancer screening. So where we stood in 2016
was quite a great deal of agreement between various approaches to cervical cancer screening. The US Preventative Services Taskforce on the first line was called
the Triple A guideline. On the second line, which was the AFCCT, the American Cancer Society and one of the pathology organizations. And the third being ACOG. Basically, they all agreed that, in the first column, for women under 21, that they should not be
receiving any cervical cytology screening at all. One exception to that is women under 21 who are HIV positive. For women between 21 and 29, the recommendation is a cervical
cytology every three years. And then for women 30 and older, either co-testing, which is a cytology plus an
HPV test every five years or cytology alone every three years. We’ve been doing this for quite a while and quite successfully. However, the FDA approved tests about two or three years ago referred to as the cobas HPV test. Recently, they also approved a second test for this purpose, which is
called primary HPV screening. And so in this particular approach, a woman comes in, has a sample taken from her vagina then sent to a lab. It’s evaluated for 14 different
types of pathaloma virus. If it is HPV negative, then she’s re-screened three years later. Down at the bottom, if she is HPV 16 or 18 positive, then she goes straight to colposcopy given
the fact that infection with HPV 16 is considered
to be fairly high risk for having an underlying
high risk like a cin 2 or a cin 3. And then the middle pathway is that if she tests positive for one of the 12 other HPVs, then
the next step is actually to do a cytology or a pap smear as the reflex test as the backup test. If that comes back normal, then she has a follow-up
HPV test 12 months later. On the other hand, if the
cytology aspects are worse, then she’s referred to colposcopy. So, basically, to summarize this, instead of starting with a pap smear or a cytology, you start with an HPV test. Most women will test negative. The 16, 18s will go straight to colposcopy and then women who test positive for other HPVs have a
reflex cytology done. Now once this was FDA-approved, a number of organizations, the Society for Gynecologic Oncology, ASCCP, ACOG, American Cancer Society, and others came up with guidelines about how to use this test. And they said that if HPV
testing alone is done, then it shouldn’t be
started until 45 years of age. Should not be done before that age. And when a woman screened negative for HPV, her screening test should be
repeated no sooner than every three years. They also went on to
say that the advantage of primary HPV only screening was that it had better sensitivity for picking up less than two or three that have passed there alone. It was less expensive than co-testing because, for most people,
advanced only an HPV test and not a pap smear. And it was very adaptable to using this as a cervical cancer screening strategy in low resource countries. Trouble is is that there
are a significant number of people who are HPV positive who don’t have hydra dysplasia but, nonetheless, many of
those women will be referred to colposcopy only to find
that it was a false alarm and they don’t actually have alesia. And so while this has
a higher pick up rate for high grade dysplasia, it
does have more false positives, meaning that more women
will have colposcopies. Now last year, the US Preventative
Services Taskforce came up with a draft of an update
for cervical cancer screening. And, by the way, this
is still in draft form. It’s not finalized yet. Probably will be in the next month or two. And what the US Taskforce suggested is that high-risk HPV
alone replace co-testing in women between 30 and 65 years of age. And then if a woman tests negative for high-risk HPV, then
her next test could be in five years rather than in three years, which is what the guideline I mentioned
a moment ago recommended. So the rationale for that was that protesting actually increased the follow-up testing by two-fold in comparison to HPV alone
but really doesn’t improve on the pickup rate of
hydra dysplasia lesions. We also thought that the
five-year interval primarily based on European studies was the best balance of harms and benefits. So I was just at the AFCP
national colposcopy meeting in Las Vegas last week. There was a lot of discussion about this. But I think, in general,
among coloscopy experts, there’s a lot of support for
this particular approach. Although they’d like
to see co-testing sort of phased out rather than
immediately going away. So assuming that the US Preventative
Services Taskforce actually does finalize the guidelines that
I mentioned a moment ago, the main area of change will
be for women 30-65 years of age who will now have the option of a cytology every three years or an HPV only test done every five years in comparison to the co-test that was in the previous guideline
every five years. Now they’re not doing any labs that are offering this yet in California nor is it a
family PATH benefit yet. But it is the direction that we’re going in in terms of cervical cancer screening. And those people are
thinking that using cytology, particularly in women 25 and older, will slowly disappear and be replaced with primary age SPE screening. Now the next area’s controversy has to do with the screening
clinical breast examination. So this summarizes breast
cancer screening guidelines that have been published by the US Preventative Services Taskforce for the first column, ACOG,
and the second column, and the American Cancer
Society in the third column. And we’ll only have time today to talk about the areas that I’ve highlighted in red, which have to do
with clinical breast exams. So this is the breast exam that we do for women 21 and older when they come in for a well woman visit but
have no complaints related to their breasts. No nipple discharge, breast tenderness, wealthiness, anything else. They’re in for a well woman visit. And, significantly, in 2015, the American Cancer Society
no longer recommended this screening clinical breast exam. And ACOG now says that
that should be based on a shared decision. So, specifically, what the
American Cancer Society said is that they do not recommend
screening clinical breast examinations among
average women at any age. The reason that they say that is that there’s no evidence of any benefits of clinical breast exam by itself or done at the same time as a mammogram in terms of whether or
not it actually leads to a higher pick-up of breast
cancer or that of survival in women who are diagnosed
with breast cancer. However, there’s moderate quality evidence that adding clinical breast exams to mammography actually increases the rate of fal-for-ens, the false-positive rate. So it really doesn’t seem
to be doing much good, but it does seem to be doing some harm. Now they do acknowledge the fact that clinical breast exams
detects a small number of additional breast
cancer cases somewhere between two and six percent
of all breast cancer cases, which are missed by mammography alone. But on the other hand, given the harms of screening clinical breast exams, false-positive tests lead to
that work-ups women don’t need. The American Cancer
Society is recommending that we no longer do them in women who have no symptoms. I think that this is an important quote from the ACS guidelines. “Recognizing the time constraints in a typical clinic visit,
clinicians should use this time instead for taking a family history,” particularly about gene
mutations like the RCA one and two or family history of breast cancer in the mom or sister before menopause, and counseling women
regarding the importance of being alert to breast changes
and the potential damages, limitations, and harms of mammography. So in other words, focus on what works. Which is looking for the possibility of a hereditary breast cancer risk and talking to women about mammography rather than
doing clinical breast exam in women who have no symptoms. So even ACOG has pulled back
on their recommendation, which had previously been that women who are older than 21 should
have a clinical breast exam every one to three years between 21 and 39 years of age. Now they say that screening clinical
breast exams can be offered in the context of shared decision making, where we inform women about
the benefits and harms of a clinical breast exam
and that for women who choose to have them, for women between 19 and 39, that they should still be done every one to three years. Who even ACOG no longer recommends that every woman needs a
screening clinical breast exam if she has no symptoms. And that’s true, by the way, regardless of which method of
contraception she’s using. All right, let’s get to our
last discussion and then in our final time and then I’ll talk very
briefly about coding. And this one has to do with the screening pelvic examination. So for decades, we’ve been doing screening bimanual pelvic examinations primarily as a way of looking for ovarian cancer. However, the US Preventative
Services Taskforce has said over the last 25 years
that there is no good way to screen for ovarian
cancer in asymptomatic women whether that’s pelvic
exam CA125 ultrasound. None of them are recommended. Now in this discussion
about screening pelvic exam, we’re only talking about
a vulva inspection, a speculum exam, and
bimanual exam at the time of a well woman visit in an
otherwise asymptomatic patient. That’s different than a
diagnostic pelvic exam in a woman who has complaints
or putting in a speculum to do a pap smear. So, historically, we have
considered the potential benefits of the screening pelvic
exam to be, to look for ovarian cancer or, let’s say, a benign ovarian tumor, a dermoid, for example. This could become torsed,
an ovarian torsion, which may cause her to lose her ovary in a woman who’s otherwise asymptomatic. Or we might find a symptomatic condition that a patient’s just
unwilling to disclose to us, or she doesn’t recognize that it’s a problem. Maybe she has urinary continents, or pelvic organ products, or sexual issues like urinary syndrome or menopause. Or maybe has a high rate
lesion of her vulva, and she just didn’t realize that that was a problem. However, there is some evidence that there are a variety of things that have been promoted as maybe reasons to do a screening pelvic exam where there’s fairly good
evidence that it’s not worthwhile. So when it comes to
looking for trichomoniasis or bacterial vaginosis or VIN or fibroids or urinary incontinence or changes in the vagina that occur during menopause, there are either no studies
which support doing them or other ways we can try and find out about them. So part of how this whole debate came to a head was that in
2014, the American College of Physicians came out
with the recommendation that basically said that we shouldn’t be doing
screening pelvic exams based on the fact that the accuracy of finding ovarian cancer was quite low, there were no studies
that assessed the benefit of screening pelvic exams for
other conditions like PIV, fibroids, other kinds of gyn cancers, outcomes are definitely
not improved in terms of reducing ovarian cancer
mortality, we know that from some very large studies
that have been done both in Europe and the US, but we know that sometimes with
the false alarms that occur, that there is harm done
to women based on findings that we find in a pelvic exam. So unnecessary laparoscopies
or laparotomies, fear and anxiety that goes along with a false-positive test, embarrassment, pain, and discomfort from
having the pelvic exam in the first place. And then there’s the unnecessary cost. So an oncologist physician said in this recommendation that we should not be doing
screening pelvic exams in asymptomatic, non-pregnant women because it’s a low-value care. It should be omitted. ACOG, on the other hand,
has kind of evolved over time. In 2015, they said that for women 21 and older, that we should
do a once-a-year look at the vulva and then inclusion of a speculum exam, a bimanual exam, or both should be a
shared informed decision between the patient and the provider. In other words, when we see women for a well woman visit,
we should tell them about the pros and cons of
having a bimanual pelvic exam and let them decide whether
or not they wanna have that done. And then, finally, the US Preventative Services
Taskforce got in the middle of this debate and in March
2017, did a reassessment of all the literature out
there and said, you know what, we still can’t make a decision. The current evidence is insufficient in order to assess the balance of the harms and the benefits of performing screening pelvic exams. But to quote them directly, they said that “clinicians are encouraged to consider risk factors for
various gynecologic conditions, like fibroids, and the
patient’s value and preferences, and engage in shared decision-making to determine whether or not
to perform a pelvic exam.” So this is a tough one for us. ACOG says, we think we know, go ahead and do it. But discuss it first. The American College of Physicians says, we know you should not
be doing a pelvic exam. And the US Taskforce says, we don’t know but you may wanna
discuss it with patients. So we’ve got three national organizations that have three different viewpoints about whether or not we should be doing
screening pelvic exams. So what are we supposed
to do with clinicians? Well, an active approach would be to say there are three
national guidelines, each one’s different, all
three of those guidelines agree that there’s no benefit
of a bimanual pelvic exam if you don’t have any symptoms, but there is evidence of false alarms and some complications. A passive approach is just not to say anything about
screening pelvic exams and only do it if the patient asks for one or to respond to questions about whether or not she
should actually have an exam. So let’s finish up with our discussion about Marisella. This will only take a few more minutes and then I’m happy to
address your questions. So we know that, a little bit about Marisella’s reproductive background. She’s now done with her well woman visit. Her blood pressure and
her BMI were recorded, a screening breast exam was done because she asked to have that performed, but she declined a screening pelvic exam. She was dispensed 13 cycles
of oral contraceptives. The face-to-face time with
Marisella was a half hour and the time that she was
counseled was 22 minutes. So the question is is how
would you code her visit on the encounter form? So remember whenever
we use clinicians check off an encounter form or a super bill, that we’re trying to tell the payer, in this case, family
doctor, other patients, it might be medical,
basically what we did, why we did it, and if we need to, to give an additional explanation to a modifier. So the work we did or the
services we performed, that’s gonna be a CPT code procedure or an ENM visit, drugs or supplies that we might have provided, why we did it, which is
the ICD 10 diagnosis, and occasionally, we
need to use a modifier. So in order for family pack, medical, any other payer, to
establish medical necessity for every what, which is the ENN code or the CPT code, there must be a why, which is the ICD 10 code. And every now and then, you need to explain unusual circumstances with a modifier. Now remember there are two different ways to calculate an E/M level. One is what’s called the key
three, the key components, which are history, physical,
medical decision-making, or we use time. But we can only use time when at least 50% of the visit was spent in counseling and coordination of care. All right? And this is just a quick reminder that when you go on the basis of time, that falls into two tables. One is for new patients on the left. On the right is for established patients, and Marisella is an established patient. And then how much face-to-face
time she actually spent with the clinician. Given how much time she
spent with the clinician, I mentioned it was 30 minutes, then this qualifies as a 99214 visit and at least half the visit was spent in counseling. Now for other payers, there’s a set of codes called a
preventive medicine visit. And by the way, medical and family tech do not recognize these but other payers may. This is based on what, for people who come in for a well woman visit,
per-tec will do this for men. Whether you’re a new patient
or an established patient, given Marisella’s age is 28,
she’s an established patient. With another payer, that one might come out with a 99395 for this
preventive medicine visit. Okay? And just to remind you, for that code set, it’s specifically intended
for check-up visits, and it’s based on your age and
a gender appropriate history. But only as much physical
exam as is indicated Marisella’s case is rather
just a blood pressure check and checking her weight. It also includes counseling,
anticipatory guidance, risk reduction, ordering laboratory tests, and addressing insignificant problems. But in this particular code set, face-to-face time, or physical exams components are not used. Okay. Now what else did we do for her? We gave her 13 cycles
of birth control pills. So we use a what’s called
a logistic code that’s used in Medicale and family pack to show that F4993 for contraceptive pills. And, also, we did a well woman visit, which is an encounter for
a routine gynecologic exam. The 01.411, which is the gyn exam without abnormal findings. Okay? In addition, we evaluated her review for birth control pills. She was using them before and continues on birth control pills. And that has its own ICD-10 code, which is Z30.41 surveillance
of contraceptive pills. So the family pack answer to the way that you would code this visit is that there were no
procedures, no supplies, she was given 14 cycles
of birth control pills. So that’s F4993 times 13 units. She had an HIV test ordered. But your clinic is not gonna bill for that unless it’s a plan of care HIV test. The lab is gonna bill for it. However, on the last list, you need to indicate what her
method of contraception is so that’s a Z30.41, which
is to say she’s a pill user. Now in family packs, you
would code this visit as a 99214 as the E/M code. And the diagnosis codes that
you would list are Z01.419, which is your gyn exam
with no abnormal findings and the Z30.41, which is sort of ends with a contraceptive pill user. Now if she were not a family pack or a Medicale patient, then it may be that the payer in that circumstance would
either cover the 99395, which is preventive medicine
visits, or as a problem visit basically and so that’s why, basically, this test of advice about how you decide which of those codes to use. So let’s wrap it up then,
and I’ll answer a few of your questions. I think the important take-home messages from this webinar are that the
well woman visit has shifted from the examination room
to the consultation room. What I mean by that is
that, in the majority of cases now for women who come in for a well woman visit, they are very much like
Marisella even in their 30s and 40s where basically the
only physical assessment which is needed is a blood pressure check and checking their
weight unless they’re due for a cervical cytology test. Or unless, of course, they have symptoms. There’s less physical
assessment and more counseling in the well woman visit. Number two is that shared decision-making
is much more prominent. So when we talk about
reproductive intentions or a family planning method
that would be most appropriate for the patient or whether
she wants a screening breast or pelvic exam. Then we talk about mammography but the age at which to start mammography. Those are not black and white issues and therefore, we use
shared decision-making to be able to discuss those decisions with our patients. Debate continues regarding the value, the timing, and certain components of the well woman visit that particularly
cervical cancer screening, which test we should
be using, intervals at which they’re offered, whether or not to do screening breast exams
and screening pelvic exams, and also to remember that not all recommended components of a well woman visit have
to be done at the same visit or necessarily by the same provider. That we need to coordinate those services to make sure that everything that needs to get done will be performed but that we don’t duplicate things. Remember that the ACA
still removes the need for out-of-pocket costs for
virtually every component of the well woman visit. Again, not an issue in
Medicale or in family pack but that is important for your patients with other kinds of insurance
where the ACA is still the law of the land and most preventive
services are available to women without any out-of-pocket costs. Other things that you can do to prepare for these kinds of
evolutionary changes is be sure to ask every patient if she also has a primary care provider. Determine the screening policies for your practice. Try to look for consistency
among your providers. It’s very upsetting for a patient if let’s say one of the nurse
practitioners tells a patient, oh no, you really don’t need a breast exam or a pelvic exam. And then she comes back
maybe a few months later with a full-body (unintelligible). Yeah, that’s something
which should be done. So when it comes to screening tests, try to develop a policy
within your practice that specifies how you all wanna do things in your practice. And make sure that
everyone, the front desk, the office people, the back office RNs, and all the clinicians are aware of the policies for your practice. Inform your clients of the changes that apply to them and also keep track of them and the changes that are made by your payers. Most benefits have not changed
yet regarding screening although things like not doing cytology on women under 21 are already
very well established. But over time, we may see changes in the policies of payers
to be more consistent with what I’ve mentioned. One last word and then
we’ll take questions. And that is I know I gave
you a lot of information, but if you’re a person who really likes to use medical apps, there are three that are really good that have to do with well woman visits. The first is one that’s actually published by the US Preventative Services Taskforce. It’s called the ARHQ Electric, I’m sorry, Electronic
Preventive Services Selector, and it will tell you what the US Taskforce basically recommends for someone like Marisella. The second is that NTWH,
the Nurse Practitioners in Women’s Health, have a really nice app that references quite a
number of different guidelines for well woman visits. And then I mentioned the QFP on a number of occasions here and the QFP has its own app as well, which
you can get at FPNTC. That’s the family planning
national training center in Kansas City. Put together this app and it basically gives you
really nice shortcuts to getting to the contents of the QFP in regard to what it recommends for well woman visits. So that, I think, is my last slide. I’m gonna wrap up the dinactic portion of the webinar. And now I’m going to a
few of your questions. So let me find them here. Okay. So first question that’s on the list is what are the California hotspots for congenital syphilis? There are a number of
them that I could tell you about off the top of my head. Otherwise, I would certainly go to the California Department
of Public Health website or just check with your local
county health department. But I know that there are certain parts of Los Angeles and Orange County that are considered to be hotspots. I understand that Fresno is considered to be a hotspot and then certain parts of the East Bay here
in Northern California in East Oakland, for example. Beyond that, I really can’t tell you off the top of my head. In the q&a, which will be posted on the familypath.org website
will probably give you more specific information from
the California Department of Public Health about those
areas that are considered to be hotspots for congenital syphilis. Second question is for women thinking that they don’t wanna have kids, wouldn’t we suggest
counseling regarding LARC as well as sterilization? Absolutely. So in that very first question, in the PATH question that I told you about earlier, if you’re
thinking about ever having kids or if you have kids currently, do you think you wanna have more? And there are some patients who will say, look, I’m absolutely 100% positive that I don’t wanna have
a child or another kid in the future. My circumstance is certainly worthwhile to at least include and vasectomy as part of the discussion. On the other hand, there are those women who will say I don’t think
I wanna have more kids, but I’m not so sure about that. And of course a discussion about one of the LARC messages applied through an IUD is completely appropriate in that circumstance because
people change their minds, and we know that those implants and IUDs work just as
well over a long period of time as physical sterilization does. But, of course, they are
completely reversible for the person who may, at some point, wanna revisit the question
after that child there. All right. Next is how would you respond to a woman who is insistent that she
have a pap smear annually? That’s really tough
just because of the fact that there are some patients who, you know, consider this, basically, who from the time that they
were little girls were told about how important it was to
have a once-a-year pap smear. So the way that we kind of respond to that where I worked over the years at general is to remind women that taxpayers not only have benefits in picking up pre-invasive
conditions in the cervix but that they also have risks that if you do pap smears too often with age, times in a woman’s life where they’re not indicated,
that you’re far more likely to get harms than you are benefits. So if you smear too often, what that leads to is the possibility
of more false-positives that lead to unnecessary colposcopies, potentially even treatments like leaks and cryos and other treatments that might be unnecessary as well. So for the patients that I’ve had who have asked, who just insist, no, I don’t wanna use
the three-year interval. I want a pap smear every year. My response to that is that given the fact that your pap smears have been negative so far, given your age group, to do a pap smear once a year is actually to do you more harm than it is good and that I’m giving you
very strongly sound advice that you should try to
live with the intervals that are considered to
be the national standard of care now because if
we screen you too often, it has the possibility of hurting you without helping you. And I’ve never had a
patient who didn’t get that. You know? I think, you know, that this discussion is a
lot more than just saying, you know what, there are harms and false alarms, there
are false-positives. But if I screen you every year instead of every three years, I’m not gonna really get any
additional damage out of them. I’m not gonna improve the pick-up rate for a high-grade dysplasia. So I don’t wanna expose you to something that will potentially hurt
you without really helping. That’s why we really wanna stick with the three-year screening intervals with cervical cytology or the
five-year screening intervals with either co-testing
now or HPV testing alone as we transition to that in the future. Next question, regarding billing. Isn’t the OC code the primary code and not the Vera 1.419? The question is I always
thought that the primary code in family path would be the method that the patient is using? And it’s a great question
and an important observation, and it points out the difference in a categorical program like family path where it’s absolutely
important and necessary to have the ICD-10 code. Florida factories use oral
contraceptives in the claim. They absolutely have to be there. However, the way that things work is that, is that the way that the CPT book is
written is it says that what you’re supposed to list on the first claim line is the main reason that the patient came into
the visit in the first place. Which in Marisella’s
case was she was there for a well woman visit, and by the way, I’m also there because I
wanna take birth control pills for another year. So those are sort of equally important. So I think in terms of making sure that the family path
claims are done correctly, and by the way, this very
likely will not be done by you as a clinician, it’s gonna be done by someone in the billing office, is that they will list the primary code for a family path patient as the method of contraception that she’s using. And then the secondary code
will be her well woman visit. Okay? But with other pairs, it
will be equally reasonable to list the checkup code first, Z01.419, and the maintenance of oral contraceptives secondly. The point is is that most
billing systems are going to pick up both codes
and they’re considered, they’re going to be considered to be accessible. That’s in family path. It’s a really good point, but what the biller is gonna wanna do is to list the family planning codes first and the check-up code second. Now a follow-up question is, if my patient does have
a primary care provider and she’s already been
seen in this calendar year for a check-up, should I not bill the 99395
preventive medicine visit when she comes to see me for a well woman visit
family planning code? That’s going to be very provider specific. Before the days of the
Affordable Care Act, many payers, and this is true of commercial health plans
like Healthnet and others, would only pay one preventive
medicine visit a year. In other words, their plane
systems were programmed in such a way that they
would only pay one 99395. I lost you there for a minute but. They would only pay one of, 99395 and that was it. But the way things work
with the Affordable Care Act with the no-cost sharing, is that there’s very specific
language that says that well woman visits may
get more than one visit. My (unintelligible), three in a year. And that being the case, the payer really should be
paying the 99395 more than once. Now a way of avoiding the miles on that might be something
that your biller puts into the remarks box which says that the well woman services
took more than one visit during the year. But the point is is that
you should not be running into problems of using that more than once during the year. So I just got the red light saying we have to wind up, but do remember that this recording will be
available and that the Office of Family Planning will
publish the text of the q&a on their website, and we’ll
try to be more specific in some of our answers. Thank you very much for hanging in there with us. – [Announcer] Thank you Dan Kol-I-kar for a very informative
and engaging presentation. We really appreciate that,
and we are ending right on time. Just to let participants know, the evaluation link and the powerpoint
slides will be remaining on the screen for a few more minutes so that you can grab those. And anyone who has registered via email
will receive the recorded webinar and the answers to
any remaining questions. Thank you, everybody, for participating and have a great day.

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