Revision 19-0; Effective July 1, 2019

 

 

This section describes the requirements and recommendations for FPP contractors pertaining to the delivery of direct clinical services to patients. In addition to the requirements and recommendations found within this section, contractors should develop protocols consistent with national evidence-based guidelines appropriate to the target population.

All providers must offer the following core family planning services:

  • Contraceptive services (pregnancy prevention and birth spacing)
    • Intrauterine devices (IUDs), contraceptive implants, oral contraceptive pills, three-month (medroxyprogesterone) injections, sterilizations, etc.
  • Pregnancy testing and counseling
  • Health screenings
    • Cervical cancer screening (Pap smears, etc.)
    • Screening for hypertension, diabetes and elevated cholesterol
  • Preconception health (e.g., screening for obesity, smoking and mental health)
  • Sexually transmitted infection (STI) services
    • Chlamydia and gonorrhea screening and treatment
    • HIV screening

 

12100 Covered Services

Revision 19-0; Effective July 1, 2019

 

The FPP seeks to promote the general and reproductive health of Texas residents by providing safe and effective family planning services to men and women through 64 years of age who reside in Texas and meet program eligibility requirements.

The following services are covered under the FPP:

  • Annual family planning and preventive health care visit;
  • Pregnancy testing and counseling;
  • Contraceptive services, all methods except elective abortion and emergency contraception, including necessary follow-up and surveillance;
  • Certain health screening and diagnostic services, as indicated:
    • Screening, diagnosis and treatment of Cervical Intraepithelial Neoplasia;
    • Diagnosis of cervical cancer;
    • Breast cancer screening and diagnosis;
    • Screening and outpatient treatment for sexually transmitted diseases and infections (STDs/STIs);
    • HIV screening;
    • Chlamydia and gonorrhea screening and treatment;
    • Syphilis screening and treatment;
    • Limited prenatal care services;
    • Recommended immunizations;
    • Screening for postpartum depression;
    • Diabetes screening;
    • Hypertension screening;
    • Screening for elevated cholesterol; and
    • Preconception health (e.g. screening for obesity, smoking and mental health).

 

12110 Requirement for Documentation of Reproductive Health Services

Revision 19-0; Effective July 1, 2019

 

All individuals should receive services related to reproductive health and/or contraception at least annually Individuals using long-acting reversible contraception (intrauterine device, implantable hormonal contraceptive agent) and patients who have undergone permanent sterilization may continue to receive services under the program if they meet eligibility requirements. 

The guiding principle of the FPP is to improve the reproductive health of women and men to ensure that every pregnancy and every baby are healthy. At each patient encounter, including encounters for treatment of other conditions (e.g., follow up of an abnormal Pap smear), the provider must educate the patient on how the service being provided relates to reproductive health or contraception, and this must be documented in the patient record.

For individuals who have undergone sterilization, and women who are post-menopausal or have had a hysterectomy, this counseling and documentation are not required when receiving covered services. This must be documented in the medical record at least annually.

 

12111 Individual Health Records and Documentation of Encounters

Revision 19-0; Effective July 1, 2019

 

Providers must ensure that a patient health record (medical record) is created for every individual who obtains clinical services (also see Section 5000, Client Records Management).

All patient health records must be:

  • A complete, legible and accurate documentation of all clinical encounters, including those that take place by telephone;
  • Written in ink, without erasures or deletions, or documented in the Electronic Health Record (EHR) or Electronic Medical Record (EMR);
  • Signed by the provider making the entry, including name of provider, provider title and date for each entry;
    • Electronic signatures are allowable to document provider review of care.
    • Stamped signatures are not allowable.
  • Readily accessible to ensure continuity of care and availability to patients; and
  • Systematically organized to allow easy documentation and prompt retrieval of information.

The individual health record must include:

  • The individual’s identification and personal data, including financial eligibility;
  • The individual’s preferred language and method of communication;
  • The individual’s contact information, including the best way and alternate ways to reach the person to ensure continuity of care, confidentiality and compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations;
  • A person’s problem list, updated as needed at each encounter, indicating significant illnesses and medical conditions;
  • A complete medication list, including prescription and nonprescription medications as well as dietary supplements, updated at each encounter;
  • A complete listing of all medication allergies and adverse reactions, and other allergic reactions, displayed in a prominent place and confirmed or updated at each encounter (if the person has no known allergies, this should be properly noted);
  • Documentation of the individual’s past medical history to include all serious illnesses, hospitalizations, surgical procedures, pertinent biopsies, accidents, exposures to blood products and mental health history;
  • A record or history of immunizations, including immunity to rubella based on a history of vaccine or documented serology testing;
  • An individual’s health risk survey and assessment, including past and current tobacco, alcohol and substance use/abuse, domestic and/or intimate partner violence and/or abuse (for any positive result, the individual must be offered referral to a family violence shelter in compliance with Texas Family Code, Chapter 91), occupational and environmental hazard exposure, environmental safety (e.g., seat belt use, car seat use, bicycle helmets, etc.), nutritional and physical activity assessment, and living arrangements, updated as appropriate at each encounter;
  • At each encounter, an encounter-relevant history and physical examination pertinent to the person’s reason for presentation, with appropriate laboratory and other studies as indicated;
  • A plan of care, updated as appropriate, consistent with diagnoses and assessments, which in turn are consistent with clinical findings;
  • Documentation of recommended follow-up care, scheduled return visit dates and follow-up for missed appointments;
  • Documentation of informed consent or refusal of services, to include at a minimum:
    • A general consent for treatment;
    • An individual’s refusal of testing;
    • Sterilization Consent form, if applicable;
    • A completed Texas Medical Disclosure Panel Consent form for any surgical services provided, if applicable;
    • For required or recommended services refused or declined by the person, documentation of the service offered, counseling provided and the person’s decision to decline;
    • The following special considerations for an adolescent’s (17 years of age and younger) consent requirements, as required by the Texas Family Code, Chapter 32 and Chapter 151:
      • Adolescents are required to have consent from a parent or guardian prior to receiving certain medical services and proof of parental consent must be included in the minor patient’s medical record when required; and
      • Adolescents are not required to have parental consent to receive pregnancy-related services (including pregnancy testing), sexually transmitted disease/infection (STD/STI) and HIV testing or STD/STI treatment;
  • Documentation of client counseling and education, with attention to risks identified in the health risk assessment; and
  • At every clinic visit, the record must be updated, as appropriate, with the reason for the visit, any assessment and the service provided documented.

 

12120 Initial Clinical Visit

Revision 19-0; Effective July 1, 2019

 

At the initial clinical visit or an early subsequent visit, a comprehensive health history must be taken to include, in addition to the elements required for the individual health record in Section 12110 above (adapt, as appropriate, to the gender of the person):

  • The reason for the visit and current health status;
  • A review of systems with documentation of pertinent positives and negatives;
  • A reproductive health history:
    • For women, this includes menstrual history, complete obstetrical history, sexual activity history (including contraceptive practices, number and gender of partners, sexually transmitted infection/sexually transmitted disease (STI/STD) and HIV history and risk factors, whether currently sexually active) and reproductive life plan;
    • For men, this includes sexual activity history (including contraceptive practices, number and gender of partners, STI/STD and HIV history and risk factors, whether currently sexually active) and reproductive life plan;
  • For women, cervical and breast cancer screening history, noting any abnormal results and treatment, and dates of the most recent testing;
  • For women, other history of gynecological conditions;
  • Other history of genital and/or urological conditions; and
  • Family health and genetic history.

At every subsequent visit, including the annual primary health care and problem visits, the record must be updated, as appropriate, and the reason for the visit and current health status documented.

 

12121 Annual Comprehensive Family Planning Visit, Physical Examination and Testing

Revision 19-0; Effective July 1, 2019

 

The annual family planning visit offers an excellent opportunity for providers to address issues of wellness and health risk reduction, as well as addressing any current findings or patient concerns. The annual visit must include an update of the person’s health record, as described in the individual health record in Section 12110 above, as well as appropriate screening, assessment, counseling and immunizations based on the individual’s age, risk factors, preferences and concerns.

All individuals must undergo a physical examination annually as part of the family planning visit. This can be deferred to a later date if the person’s current history and health status do not suggest issues requiring more urgent examination. However, the annual physical examination should not be deferred longer than six months, unless the clinician identifies a compelling reason for extended deferral. Such reason must be documented in the individual’s record. Any breast or pelvic examination should be performed only with the consent of the person. Individuals must be offered a suitable method of contraception, such as oral contraceptives, without delay even if the physical examination is put off temporarily or an otherwise asymptomatic individual declines any or all components of the examination.

It is recommended that the family planning visit include all the following components at least annually, in addition to any other appropriate elements as suggested by history and presenting signs and symptoms (all findings, including tests, results and the individual’s notification of results, should be documented in the medical record, as well as an individual’s refusal or other reason for not testing or performing a specified part of the examination):

  • Measurement of height, weight and blood pressure (BP) screening for hypertension;
  • Calculation of body mass index (BMI) with assessment for underweight, overweight or obesity, with counseling (if indicated) on achieving and maintaining a healthy body weight (an adult BMI calculator and a BMI calculator for children and teens are available from the Centers for Disease Control and Prevention);
  • For females:
  • Clinical breast examination, breast cancer risk assessment and breast cancer screening, as appropriate based on person’s age, risk and preferences;
    • Counseling on breast awareness and advice to report any symptom or sign that is concerning to the individual; 
    • Screening for cervical cancer beginning at 21 years of age, regardless of sexual history, and continuing as indicated based on the individual’s age, prior test results and treatment history; and
    • Pelvic examination (for all consenting individuals 21 years and older, only if indicated by the medical history in consenting individuals less than 21 years of age) to include the following elements:
      • Visual examination of the external genitalia, vaginal introitus, urethral meatus and perianal area;
      • Speculum examination of the cervix and vagina; and
      • Bimanual examination of the cervix, uterus and adnexa, and when indicated, rectovaginal examination;
  • For males:
    • Visual and manual examination of the external genitalia (scrotum, penis and testicles) and visual inspection of the perianal area;
    • Assessment for hernia;
    • Palpation of the prostate as indicated by history and person’s age; and
    • Advice on testicular awareness and recommendation to report any symptom or sign that is concerning to the person;
  • Other examination as indicated by history, signs and symptoms, and the individual’s concerns (e.g., thyroid, heart, lungs, abdomen, etc.):
    • Diabetes screening as appropriate for age and risk factors;
    • Sexually transmitted infections;
    • Pregnancy testing, available on-site (if the pregnancy test is positive, the person must be given information on good health practices during pregnancy and given or referred for appropriate physical evaluation and initiation of prenatal care, preferably within 15 days);
    • Rubella immunity testing in women of reproductive age if the status cannot be determined by history or previous testing;
    • Cholesterol and/or serum lipid testing;
    • Thyroid stimulating hormone;
    • Immunizations as indicated (health care providers can voluntarily participate in the Texas Department of State Health Services (DSHS) Adult Safety Net (ASN) vaccine program, which provides vaccines at no cost); and
    • Other testing, if indicated;
  • Appropriate family planning counseling and treatment; and
  • Healthy lifestyle interventions and counseling, as indicated based on age, risk factors, and client interest and receptiveness.

 

12122 Counseling and Education

Revision 19-0; Effective July 1, 2019

 

All individuals must receive accurate person-centered education and counseling in their preferred language, presented in a way they are able to understand and to demonstrate their understanding, and documented in the medical record. The intent of individual education is to enable the person to understand the range of available services and how to access them, to make informed decisions about family planning, to reduce personal health risk and to understand the importance of recommended tests, health promotion and disease prevention strategies.

Specific clinical policies must be in place to address counseling and other services provided to adolescents 17 years of age and younger, to include the following at a minimum:

  • Counseling of adolescents must include these topics:
    • All medically approved methods of contraception, including abstinence;
    • Prevention of STDs/STIs and HIV;
    • Domestic, partner, dating and family violence, and the offer of assistance as needed; and
    • Recognition and avoidance of sexual coercion.
  • Counseling and clinical services to adolescents must be expedited so that appointments are made available as soon as possible.
  • Adolescents must be assured that their privacy and confidentiality will be protected within the parameters of applicable law, including the Health Insurance Portability and Accountability Act (HIPAA), Texas Family Code, Chapter 32, and Section 11000, Consent.

Details of appropriate educational interventions are included in this manual. In addition, links are provided to information of use to individuals and educators at the end of most sections.

 

12130 Requirements for Policies to Ensure Appropriate Follow-up and Continuity of Care

Revision 19-0; Effective July 1, 2019

 

Providers must develop and maintain policies and procedures to ensure proper timely follow-up and continuity of care, to include at a minimum:

  • Tracking pending tests until results are reviewed by the provider and the individual is notified of results and recommended follow-up;
  • Documentation of all tests and results in the individual health record;
  • A mechanism to inform individuals promptly of test results that protects the person’s privacy and confidentiality while supporting and promoting timely appropriate follow-up;
  • A mechanism to track individual compliance with recommended follow-up care, schedule return visits and follow-up on missed appointments; and
  • A process to ensure compliance with all applicable state and local laws for disease reporting.

Before a person is considered lost to follow-up, the contractor must make at least three documented separate attempts to contact the person, using an accelerated protocol where subsequent attempts involve a more intensive effort to contact the person. Examples: A telephone call on the first attempt, a letter by regular mail on the second attempt and a certified letter on the third attempt. Providers should develop processes that are adapted to the circumstances of the population they serve, and adapt their usual processes based on their knowledge of the circumstances and preferences of the individual they are attempting to contact. 

 

12131 Problem Visits

Revision 19-0; Effective July 1, 2019

 

For all problem visits, the following elements must be documented in the medical record:

  • Reason for the visit;
  • Appropriate interval medical history and focused history relevant to the problem reported; and
  • Relevant physical examination and testing, as indicated, as well as an assessment and prescribed treatment.

 

12132 Referrals

Revision 19-0; Effective July 1, 2019

 

When a person is referred to another provider of services for consultation or continuation of care, the chart must reflect a record of the purpose for the referral, the name of the provider consulted or referred to, counseling of the person regarding the purpose of the referral and answering any questions the person has about the referral. Pertinent individual information and appropriate portions of the medical record must be provided to the referral clinician and must also be documented in the medical record. The results of the consultation or referral must be followed up on and documented in the medical record.

When services covered under the FPP are to be provided by referral, the contractor must establish a written agreement with a referral resource for the provision of services and reimbursement of costs and ensure that the patient is not charged by the referral resource for these services.

Contractors must maintain a written policy reflecting these requirements for referral activities.

 

12133 Prescriptive Authority Agreements

Revision 19-0; Effective July 1, 2019

 

When services are provided by an advanced practice registered nurse (APRN) and/or physician assistant, it is the responsibility of the contractor to ensure that a properly executed prescriptive authority agreement (PAA) is in place for each provider, as required by Texas Administrative Code Title 22, Part 9, Chapter 193. This is true whether the provider is employed by the contractor or is providing services by subcontract with, or referral by, the contractor. The PAA must meet all the requirements delineated in the Texas Occupations Code, Chapter 157, including but not limited to, the following minimum criteria:

  • Be in writing and signed and dated by the parties to the agreement;
  • Include the name, address and all professional license numbers of all parties to the agreement;
  • State the nature of the practice, practice locations or practice settings;
  • Identify the types or categories of drugs or devices that may be prescribed, or the types or categories of drugs or devices that may not be prescribed;
  • Provide a general plan for addressing consultation and referral;
  • Provide a plan for addressing patient emergencies;
  • Describe the general process for communication and sharing of information between the physician and the APRN or physician assistant to whom the physician has delegated prescriptive authority related to the care and treatment of individuals;
  • If alternate physician supervision is to be utilized, designate one or more alternate physicians who may:
    • Provide appropriate supervision on a temporary basis in accordance with the requirements established by the PAA and the requirements of this section; and
    • Participate in the prescriptive authority quality assurance and improvement plan meetings required under this section; and
  • Describe a prescriptive authority quality assurance and improvement plan and specify methods for documenting the implementation of the plan that includes:
    • Chart review, with the number of charts to be reviewed determined by the physician and APRN or physician assistant; and
    • Periodic face-to-face meetings between the APRN or physician assistant and the physician at a location determined by the physician, APRN or physician assistant.

The PAA need not describe the exact steps that an APRN or physician assistant must take with respect to each specific condition, disease or symptom. The PAA and any amendments must be reviewed at least annually, dated and signed by the parties to the agreement. A copy of the current PAA must be maintained on-site where the APRN or physician assistant provides care.

 

12134 Standing Delegation Orders

Revision 19-0; Effective July 1, 2019

 

When services are provided by unlicensed and licensed personnel, other than advanced practice nurses or physician assistants, whose duties include actions or procedures for a population with specific diseases, disorders, health problems or sets of symptoms, the clinic must have written standing delegation orders (SDOs) in place. SDOs are distinct from specific orders written for an individual. SDOs are instructions, orders, rules, regulations or procedures that specify under what set of conditions and circumstances actions should be instituted. The SDOs delineate under what set of conditions and circumstances an RN, LVN or non-licensed health care provider (NLHP) may initiate actions or tasks in the clinical setting and provide authority for use with individuals when a physician or advance practice provider is not on the premises, and/or prior to being examined or evaluated by a physician or advanced practice provider. Example: An SDO for assessment of blood pressure/blood sugar which includes an RN, LVN or NLHP that will perform the task, the steps to complete the task, the normal/abnormal range and the process of reporting abnormal values.

Other applicable SDOs when a physician is not present on-site may include, but are not limited to:

  • Obtaining a personal and medical history;
  • Performing an appropriate physical exam and the recording of physical findings;
  • Initiating and performing laboratory procedures;
  • Administering or providing drugs ordered by voice communication with the authorizing physician;
  • Providing pre-signed prescriptions for:
    • oral contraceptives;
    • diaphragms;
    • contraceptive creams and jellies;
    • topical anti-infective for vaginal use; or
    • antibiotic drugs for treatment of STIs/STDs;
  • Handling medical emergencies to include on-site management, as well as possible transfer of the individual;
  • Giving immunizations; or
  • Performing pregnancy testing.

The SDOs must be reviewed, signed and dated by the supervising physician who is responsible for the delivery of medical care covered by the orders and other appropriate staff at least annually, and maintained on-site.

 

12140 References

Revision 19-0; Effective July 1, 2019

 

American Academy of Family Physicians (2017). Summary of recommendations for clinical preventive services. AAFP Policy Action Order No. 1968. Available at http://www.aafp.org/dam/AAFP/documents/patient_care/clinical_recommendations/cps-recommendations.pdf.

American College of Obstetricians and Gynecologists (2012). Committee opinion 534: Well-woman visit. Obstet Gynecol 120: 421-424. Available at http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Gynecologic_Practice/Well-Woman_Visit.

Centers for Disease Control and Prevention. Content of care for women website. Available at http://www.cdc.gov/preconception/careforwomen/index.html.

Centers for Disease Control and Prevention. Clinical content of care for men website. Available at http://www.cdc.gov/preconception/careformen/index.html.

Centers for Disease Control and Prevention (2014). Providing quality family planning services. MMWR 63(4). Available at http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf.

Centers for Disease Control and Prevention (2016). Update: Providing quality family planning services - Recommendations from CDC and the U.S. Office of Population Affairs, 2015. MMWR 65(9); 231-234. Available at https://www.cdc.gov/mmwr/volumes/65/wr/mm6509a3.htm.

Centers for Disease Control and Prevention. Immunization schedules website. Available at http://www.cdc.gov/vaccines/schedules/.

 

12200 Family Planning and Contraceptive Services

Revision 19-0; Effective July 1, 2019

 

12210 Reproductive Life Plan

Revision 19-0; Effective July 1, 2019

 

Providers should encourage all individuals to develop a reproductive life plan, which is an outline of each person’s plan for having children. Questions such as the following can be useful in helping individuals to develop the plan:

  • Do you have children now?
  • Do you desire to have (more) children?
  • How many children would you like to have and when?

Of course, providers and individuals should understand that such plans can change with time. Providers should take the individual’s stated plan into account in counseling on contraceptive and family planning services.

  • If the person is sexually active and does not desire pregnancy, offer contraceptive services.
  • Provide pregnancy testing and counseling to any female who may be pregnant or who requests such testing. Initiate or provide referral for prenatal services if positive.
  • If pregnancy is currently desired and the woman is not pregnant, offer services to help her and her partner to achieve a safe and healthy pregnancy.

 

12220 Contraceptive Counseling and Education

Revision 19-0; Effective July 1, 2019

 

At each encounter for services, individuals must receive patient-centered counseling and education to enable them to make informed decisions about family planning, including information on preventing STDs/STIs and HIV, the results of the physical examination and other testing, method-specific counseling as described below, and other counseling as indicated by the history and clinical evaluation.

Providers must offer individuals a wide array of contraceptive options appropriate for the person’s health status and reproductive plan. A six-step approach that seeks to engage the person in the decision-making process, while addressing individual personal and cultural preferences, will improve individual satisfaction and the likelihood that the selected method will be used correctly and consistently.

  • Step One – Establish and maintain rapport with the person. Some ways to do this include:
    • Ask open-ended questions;
    • Ensure confidentiality and privacy and explain how confidential information may be used;
    • Listen to and observe the person; and
    • Encourage questions and provide culturally sensitive answers that demonstrate knowledge of the subject matter in language the person understands.
  • Step Two – Obtain social and clinical information from the person to include the following:
    • Health history;
    • Current reproductive life plan;
    • Contraceptive experience and possible preferences; and
    • Assessment of sexual health:
      • Past and current contraceptive practices;
      • Partner history (e.g., number, gender, whether concurrently monogamous);
      • Current and past STD/STI prevention (e.g., limiting partners, use of condoms, barriers to condom use, consistency of use); and
      • Prior treatment for, and possible exposure to, STDs/STIs.
  • Step Three – Work interactively with the person to choose the most appropriate contraceptive method for the individual.
    • Educate the person about all contraceptive methods that are safe and appropriate for that individual. An online patient decision support tool is available from the Association of Reproductive Health Professionals;
    • Counsel individuals on the relative effectiveness of methods, correct use of methods, potential noncontraceptive benefits (e.g., reduced risk of iron-deficiency anemia with combination hormonal contraceptives) and method side effects, working with the individual or couple to select the method that best meets their needs and wishes;
    • Inform individuals that contraceptive methods other than condoms provide no protection from STDs/STIs, including HIV, and that condoms used correctly and consistently do help to reduce the risk of STDs/STIs, including HIV; and
    • Help the person to identify barriers to correct contraceptive method use and develop solutions to overcome barriers.
  • Step Four – Perform a physical evaluation appropriate to the method chosen, when warranted. In most cases, no physical examination or laboratory testing is necessary prior to initiating a contraceptive method.
    • Blood pressure should be recorded prior to starting combination hormonal contraception.
    • Current pregnancy status should be determined at the time of service for any woman receiving contraceptive services, but routine pregnancy testing is not necessary if it is possible to be reasonably certain that she is not pregnant. A provider may be reasonably certain that a woman is not currently pregnant if she has no signs or symptoms of pregnancy (either intrauterine or ectopic) and meets at least one of the following criteria:
      • Less than or equal to seven days since the start of normal menses;
      • No sexual intercourse since the beginning of the last normal menses;
      • Has been using a reliable method of contraception correctly and consistently;
      • Less than or equal to seven days since a spontaneous or induced abortion;
      • Less than or equal to four weeks postpartum; or
      • Less than six months postpartum, amenorrhea since delivery and exclusively or almost exclusively breast feeding (at least 85% of infant feedings are breast feedings).
    • Weight assessment is not necessary before initiating a contraceptive method because obesity alone is not a contraindication to any method. However, a baseline weight measurement may aid in assessing the possible effect of a chosen method on weight change.
    • Certain tests and components of the physical examination may provide logistical, economic or emotional barriers to contraceptive access or acceptance for some women. In most cases, many of these interventions can be safely delayed or avoided altogether, if necessary, to enable a healthy individual to initiate an appropriate and preferred method (although there may be other health care-related indications for the interventions). The following tests and examinations are not necessary prior to initiating a contraceptive method:
      • Pelvic examination, except when fitting a diaphragm or inserting an IUD;
      • Cervical, breast or other cancer screening;
      • HIV screening;
      • Laboratory testing for hemoglobin, glucose, lipid or liver enzyme levels, or for thrombogenic mutations; or
      • Any physical examination prior to distributing condoms.
  • Step Five – Once a method of contraception is selected, the provider should provide counseling on correct and consistent use, assist the individual to develop a plan for correct use and follow-up and confirm the person’s understanding. Certain considerations may increase the likelihood of correct and consistent use.
    • Ideally, the method should be dispensed on-site (see on-site pharmacy requirements for contractors in Section 12222.2, Specific Method Access Requirements for Contractors) and started at the time of the visit (rather than waiting for the next menses), if the provider can be reasonably certain the woman is not pregnant (see Step Four above for criteria to determine with reasonable certainty that a woman is not currently pregnant).
    • Multiple cycles (ideally a full year’s supply) of oral contraceptive pills, the patch or the ring should be prescribed or provided to reduce the number of return visits necessary.
    • Make condoms easily available. Note: All FPP contractors must make barrier methods and spermicides available on-site.
    • If the individual’s chosen method is not available immediately or on-site, provide another method on the day of the visit to be used until the chosen method can be started.
  • Step Six – Help the person develop a plan for correct and consistent use of the chosen method and provide a plan for follow-up.
    • Explore possible reasons for incorrect or inconsistent use and help develop strategies to deal with these. For example:
      • Suggest a daily text message or a sign on the bathroom mirror to routinize daily pill taking.
      • Discuss ways to ensure timely return for injections.
      • Discuss side effects, a common reason for method discontinuation and ways to deal with these.
    • Create a follow-up plan with the person, considering the person’s individual needs and perceived risk of method lapse or discontinuation.
    • Confirm the person’s understanding of the information given and document this in the medical record.
      • The teach-back method, in which the individual demonstrates understanding of the information by repeating back the messages received, is a good way to confirm understanding and to increase retention of the information received.
      • Provide counseling with teach-back of the following topics, at a minimum:
        • Real-world method effectiveness;
        • Correct method uses and common side effects;
        • Back-up contraceptive methods, including issues related to discontinuation of the chosen method;
        • Whether or not the method protects against STDs/STIs;
        • Signs of rare, but serious, complications and what to do if any of these signs occurs;
        • How to seek urgent or emergency care, including a 24-hour emergency telephone number; and
        • When to return for follow-up.

 

12221 Relative Method Effectiveness

Revision 19-0; Effective July 1, 2019

 

The following contraceptive methods are approved for reimbursement under the FPP. (see pharmacy requirements for FPP contractors in Section 9000, Pharmacy, and Section 12222.2, Specific Method Access Requirements for Contractors). 
It is the contractor’s responsibility to ensure that all contraceptive methods approved for reimbursement by the FPP are made available at no additional charge to the individual.

Relative method effectiveness (range of effectiveness for 100 women using the method for one year) is indicated in parentheses, if reported values are available.  Actual effectiveness depends on correctness and consistency of use. Higher rates of effectiveness are seen with perfect use. Real-world effectiveness is generally reflected in the lower end of the effectiveness range.

  • Extremely effective (99%)
    • Total sexual abstinence;
    • *Contraceptive implant;
    • *Intrauterine device; and
    • Male or female sterilization.
  • Less effective (ranges of effectiveness are shown where the source used provides a range or multiple sources provide differing rates or ranges)
    • Lactational amenorrhea (98-99%; must be less than six months postpartum, amenorrheic and providing 85-100% of infant feedings as breast feedings);
    • Progestin injection (Depo-Provera, 94-97%);
    • Hormonal contraceptive pills (91-92%);
    • Hormonal contraceptive patch (91-92%);
    • Vaginal ring (91-92%);
    • Diaphragm (82-88%);
    • Male condom (82-85%);
    • Female condom (79%);
    • Withdrawal (“pulling out,” 78-82%);
    • Cervical cap (71-86%);
    • Fertility awareness (“rhythm,” 75-76%);
    • Spermicide (71-72%); and
    • Sponge (68-88%, more effective in parous women).

*Long-acting reversible contraceptive methods.

 

12222 Long-Acting Reversible Contraceptive (LARC) Methods

Revision 19-0; Effective July 1, 2019

 

Because of their safety, reversibility, ease of use and very high real-world effectiveness, providers are encouraged to make LARC agents and devices (i.e., the intrauterine device and the subdermal contraceptive implant) available to all who are candidates for their use. See Long-Acting Reversible Contraception Program from the American Congress of Obstetricians and Gynecologists for information and resources on the use of LARCs.

For more information on implementing a program to provide LARCs, see the Texas LARC Toolkit on the Healthy Texas Women website.

 

12222.1 Consent for Sterilization

Revision 19-0; Effective July 1, 2019

 

For individuals who choose male or female sterilization, two consent forms are required to be signed by the person after counseling on method-specific risks and benefits is provided and all the person’s questions have been answered:

  • The Sterilization Consent form must be signed by the person at least 30 days and not more than 180 days prior to the procedure. An exception is made if the person undergoes emergency abdominal surgery or preterm birth, in which case the form must be signed at least 72 hours before the sterilization procedure (and at least 30 days prior to the expected date of delivery if preterm birth is the reason for the exception).
  • A Texas Medical Disclosure Panel Consent for the surgical procedure by which sterilization will be performed must be signed by the person after full disclosure of the risks and possible benefits is provided and all the patient’s questions are answered.

 

12222.2 Specific Method Access Requirements for Contractors

Revision 19-0; Effective July 1, 2019

 

  • LARC methods (i.e., the intrauterine device and the subdermal contraceptive implant) must be available on-site or by referral.
  • Male and female sterilization must be made available, subject to program funding stipulations.
  • All contractors must make injectable hormonal contraceptive agents, male and female condoms, spermicides, diaphragms, contraceptive sponges, cervical caps, and counseling and education on sexual abstinence available on-site.
  • Contractors who are subject to the requirement to maintain a Class D pharmacy must also make oral and transdermal hormonal contraceptive agents or vaginal hormonal contraceptive rings available on-site.

The table below outlines the requirements for on-site availability of contraceptive methods and anti-infective agents for FPP contractors:

Contraceptive Method or Anti-infective Agent On-site Availability Required
  Class D Pharmacy Class D Pharmacy Exempt
Anti-infective agents for treatment of STDs/STIs  
Barrier methods and spermicides

Injectable hormonal contraceptives

Oral contraceptives

 

Transdermal hormonal contraceptive (patch) and/or vaginal hormonal contraceptive (ring)

 

Sexual abstinence education and counseling

 

12223 Contraceptive Methods that May Be Provided by Referral

Revision 19-0; Effective July 1, 2019

 

If the clinicians associated with an FPP contractor do not provide covered contraceptive services that require a special level of training or expertise (e.g., sterilization, intrauterine device, hormonal implant and diaphragm fitting), these services may be offered by referral to another provider at no additional cost to the individual. FPP contract clinics that offer such services by referral must have a written agreement with the referral provider to offer the method or service under this condition.

Notes:

  • Abortion is not considered a method of family planning and no state funds appropriated to the department shall be used to pay the direct or indirect costs (including overhead, rent, phones and utilities) of abortion procedures provided by contractors.
  • Emergency contraceptive pills (ECs or ECPs) and related provider services are not reimbursable under the FPP.

 

12224 References and Resources

Revision 19-0; Effective July 1, 2019

 

References

Centers for Disease Control and Prevention (2014). Providing quality family planning services. MMWR 63(4). Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6304a1.htm (web) http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf (PDF).

Centers for Disease Control and Prevention (2016). Update: Providing quality family planning services - Recommendations from CDC and the U.S. Office of Population Affairs, 2015.  MMWR 65(9); 231-234. Available at https://www.cdc.gov/mmwr/volumes/65/wr/mm6509a3.htm.

Centers for Disease Control and Prevention. U.S. selected practice recommendations for contraceptive use, 2016. MMWR 65(No. 4). Available at https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html (web) https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6504.pdf.

Resource for Patients and Educators

Association of Reproductive Health Professionals. Method Match. Online decision support tool to help patients compare and select from different methods of contraception. Includes information on relative effectiveness of methods. Available at http://www.arhp.org/methodmatch/.

Resource for Providers

American Congress of Obstetricians and Gynecologists. Long-acting reversible contraception program web page. Provides information, clinical guidance and educational materials on long-acting reversible contraceptives. Available at https://www.acog.org/About_ACOG/ACOG_Departments/Long_Acting_Reversible_Contraception

 

12230 Preconception Services

Revision 19-0; Effective July 1, 2019

 

The goal of preconception care is optimizing the health of every woman to lay the foundation for the best possible outcome of every pregnancy. Because almost half of all pregnancies in the United States are unplanned, and most pregnancies occur in women who did not have a specific preconception care visit prior to becoming pregnant, providers should keep preconception care in mind at every encounter with a woman of childbearing potential.

Good preconception care incorporates all components of general health care as described elsewhere in this manual. Attention should be paid to the following components:

  • Optimization of known chronic medical conditions, such as diabetes, hypertension, thyroid disease, epilepsy, asthma, etc.:
    • A normal hemoglobin A1c prior to, and early in, pregnancy can substantially reduce the risk of birth defects in the offspring of mothers with Type 1 and Type 2 diabetes.
    • Women with hyperthyroidism or hypothyroidism should be treated, as necessary, to ensure that they are euthyroid prior to, and during, pregnancy to reduce the risk of miscarriage and preterm birth.
    • Women with a history of phenylketonuria should be counseled on the need to follow a low-phenylalanine diet before, and during, pregnancy to reduce the risk of birth defects and serious developmental delay in the offspring.
  • Screening, as indicated, for any conditions that may be undiagnosed.
  • Confirming that immunizations are current.
  • Medications (prescription and nonprescription) and potential radiation exposure in early pregnancy:
    • In general, the lowest effective dose of necessary medications is preferred, but individuals should be cautioned against discontinuing or changing medications without first consulting their doctor because an untreated or incompletely treated medical condition may pose greater risk to the fetus and mother than the medication prescribed.
    • Some known teratogenic medications include warfarin, valproic acid, carbamazepine, isotretinoin and angiotensin-converting enzyme inhibitors. Note: For more individual and provider information on risk associated with specific exposures to medications and other environmental factors, consult the web site of the Organization of Teratology Information Specialists.
  • Prevention of STDs/STIs.
  • Nutrition and food insecurity.
  • Occupational and environmental exposures to health risks and teratogens.
  • Tobacco and substance use and other high-risk behaviors.
  • Family medical history and genetic risk.
  • Domestic, intimate and partner violence.
  • Social issues, such as homelessness.
  • Mental health.

 

12231 References and Resources

Revision 19-0; Effective July 1, 2019

References

American Academy of Pediatrics/American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care 7th Ed. (2012). Ch. 5, pp. 95-106.

American College of Obstetricians and Gynecologists. Committee opinion 313: The importance of preconception care in the continuum of women’s health care.  Obstet Gynecol (2005). 106: 665-666. Available at http://www.acog.org/Resources_And_Publications/~/link.aspx?_id=75AD1BF47A76489F8E719EA5E3F22797&_z=z.

Centers for Disease Control and Prevention. Recommendations to improve preconception health and health care – United States. MMWR (2006). 55(RR06): 1-23.  Available at http://www.cdc.gov/mmWR/PDF/rr/rr5506.pdf.

Organization of Teratology Information Specialists. Mother to Baby: Medications and more during pregnancy and breastfeeding. Available at http://mothertobaby.org/fact-sheets-parent/.  (Provides information for patients and health care providers on teratogenic risk of drugs and other exposures in pregnancy.)

Resources for Patients and Providers

American Society for Reproductive Medicine. Available at http://www.reproductivefacts.org/. (Information for patients on a variety of topics related to fertility and infertility.)

Centers for Disease Control and Prevention. Content of care for women website. Available at http://www.cdc.gov/preconception/careforwomen/index.html.

Centers for Disease Control and Prevention. Clinical content of care for men website. Available at http://www.cdc.gov/preconception/careformen/index.html.

Centers for Disease Control and Prevention. Preconception health and health care web site. Contains links to resources for patients, providers and patient educators on planning for a healthy pregnancy. Available at http://www.cdc.gov/preconception/index.html.

 

12300 Screenings

Revision 19-0; Effective July 1, 2019

 

 

12310 Cervical Cancer Screening

Revision 19-0; Effective July 1, 2019

 

The summary of cited guideline recommendations provided in this section reflects the ages of eligibility for the FPP and does not include guideline recommendations for individuals outside this range.

Guidelines were reviewed from a variety of medical specialty organizations and U.S. government agencies. Where a slight divergence was found among guidelines from different organizations, an attempt was made to synthesize the recommendations so that all recommendations are represented cohesively in the summary below. 

Most cases of cervical cancer occur in women who have never had screening or have had inadequate screening. It is estimated that half of women who receive a diagnosis of cervical cancer have never had cervical cytology testing and an additional 10% have not had screening in the five years prior to the diagnosis of cancer. Providers are encouraged to implement and participate in programs aimed at increasing the percentage of women in their communities who receive indicated cervical cancer screening.

General Considerations

  • Cervical cancer screening should begin at age 21. Except for women who are infected with HIV or otherwise immunocompromised, screening should not be performed prior to age 21.
  • Women with the following risk factors are at higher risk and may require more frequent screening than described in this manual, which is intended for women of average risk:
    • Women with HIV infection or other reason for immunocompromise (e.g., history of solid organ transplant);
    • History of in utero exposure to diethylstilbesterol; and
    • Prior treatment for CIN 2, CIN 3 or cervical cancer.
  • Either liquid-based or conventional (PAP smear) methods of cervical cytology are acceptable.
  • When human papillomavirus (HPV) testing is performed, it should include testing to detect only those HPV genotypes with known carcinogenic potential, so-called high-risk HPV genotypes. Testing for low-risk genotypes, those without demonstrated carcinogenic potential, should not be performed.  References to HPV testing in the remainder of this topic section are for high-risk HPV only.
  • Screening guidelines should be applied to women who have received the HPV vaccine in the same way as for women who have not received the vaccine.

 

12311 Screening Frequency and Response to Abnormal Findings

Revision 19-0; Effective July 1, 2019

 

  • Routine annual cervical cancer screening is not appropriate for women of average risk in any age group. 
  • Women age 21 through 29 should undergo screening every three years by cervical cytology testing alone, with reflex human papillomavirus (HPV) testing when cytology reveals atypical squamous cells of undetermined significance (ASCUS). Co-testing (cervical cytology combined with routine HPV testing) should not be performed in women younger than 30 years of age.
  • For women age 25 through 29, the FDA-approved primary HPV screening test may be considered as an alternative to cytology-based screening, although cytology alone with reflex HPV testing when cytology reveals ASCUS is recommended by major professional society guidelines. If the primary HPV test is to be used for screening, it should be done according to interim guidance provided by the American Society for Colposcopy and Cervical Pathology and the Society of Gynecologic Oncology.
  • For women age 30 through 64, published guidelines recommend screening by any of three methods:
    • Co-testing (combined cervical cytology and HPV testing) every five years;
    • Cervical cytology testing alone, with reflex HPV testing when cytology reveals ASCUS, every three years; and
    • Screening with the FDA-approved primary HPV screening test every five years. If the primary HPV test is to be used for screening, it should be done according to interim guidance provided by the American Society for Colposcopy and Cervical Pathology and the Society of Gynecologic Oncology.
  • It is reasonable to perform annual cervical cytology testing in women with in utero exposure to diethylstilbestrol.
  • For any individual with an abnormal result, further testing and follow-up should be dictated by findings, diagnosis and current evidence-based guidelines, such as that of the American Society for Colposcopy and Cervical Pathology.

Discontinuation of Screening

For women in the FPP age group, screening should be discontinued after a hysterectomy with removal of the cervix in individuals with no prior history of CIN 2 or greater.

 

12312 References

Revision 19-0; Effective July 1, 2019

 


American Society for Colposcopy and Cervical Pathology (2013). Consensus guidelines for managing abnormal cervical cancer screens and CIN/AIS. Available at http://www.asccp.org/asccp-guidelines.
Huh, W. K., Ault, K. A., Chelmow, D., Davey, D. D., Goulart, R. A., Garcia, F. A., Einstein, M. H. (2015). Use of primary high-risk human papillomavirus testing for cervical cancer screening: Interim clinical guidance. Gynecol Oncol, 136(2), 178-182.

Practice Bulletin No. 168: Cervical cancer screening and prevention. (2016). Obstet Gynecol, 128(4), e111-e130.

U.S. Department of Health and Human Services Panel on opportunistic infections in HIV-infected adults and adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health and the HIV Medicine Association of the Infectious Diseases Society of America. Available at https://aidsinfo.nih.gov/guidelines/html/4/adult-and-adolescent-opportunistic-infection/0.

U.S. Preventive Services Task Force, Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Wong, J. B. (2018). Screening for cervical cancer: US Preventive Services Task Force Recommendation Statement. JAMA, 320(7), 674-686.

 

12320 Breast Cancer Screening

Revision 19-0; Effective July 1, 2019

 

The summary of cited guideline recommendations provided in this section reflect the ages of eligibility for the FPP and do not include guideline recommendations for individuals outside this range.

Risk Screening and Individual Counseling

All females should have an assessment of their risk for breast cancer, updated periodically, to include the individual’s age and ethnicity, personal and family history of breast cancer, other relevant genetic predisposition to breast cancer and any history of chest radiation (particularly before age 30). A risk calculator is available from the National Cancer Institute for an individual’s five-year risk of developing breast cancer (for women age 35 and older).

All individuals should be counseled on breast awareness, advised to be familiar with their breasts and to promptly report any changes (such as a mass, lump, thickening or nipple discharge).

 

12321 Screening Frequency

Revision 19-0; Effective July 1, 2019

 

The following considerations* apply to women age 40 and older who do not have preexisting breast cancer or other high-risk breast lesion and who do not have a known underlying genetic mutation (such as a BRCA1 or 2 mutations, or other familial breast cancer syndrome) or a history of chest radiation at an early age. 

  • All individuals age 50 through 64 should be offered screening mammography every other year. 
  • The decision for screening mammography in women age 40 through 49 should be individualized:
    • While screening mammography may reduce breast cancer-related deaths in this population, the number of deaths prevented is less than in older populations and the number of false-positive mammography results and negative biopsies is higher.
    • Women who undergo regular screening mammography face a risk of the diagnosis and subsequent treatment of breast cancer that would not otherwise have become apparent or threatened their health during their lifetime (overtreatment).
    • Women with a first-degree relative (parent, sibling or child) with breast cancer are at increased risk and may benefit more from screening in their 40s than average-risk women.
    • Women who place a higher value on the potential benefits of screening than on the potential harms may choose, and should be allowed to, undergo biennial screening beginning sometime between age 40 and 49.
  • Digital mammography combined with breast tomosynthesis may improve the rate of cancer detection and decrease call-back rates in some women, although this practice may increase the total radiation dose.
  • There is insufficient evidence to assess the balance of benefits and harms for the use of breast ultrasonography, magnetic resonance imaging or other methods of adjunctive screening in women with dense breasts identified on an otherwise negative screening mammogram.

More frequent or earlier screening mammography may be considered in women with increased or uncertain individual breast cancer risk and in other circumstances where the balance of potential benefits and harms of screening is felt to justify it.

*Note: The recommendations for frequency of mammography screening described above come from the U.S. Preventive Services Task Force Recommendation Statement on Screening for Breast Cancer. The National Comprehensive Cancer Network recommends annual screening mammography be offered to all asymptomatic women age 40 and older. Links to both guidelines are provided in Section 12323, References and Resources.

 

12322 Follow-up and Referral for Treatment

Revision 19-0; Effective July 1, 2019

 

Any individual with an abnormality identified on screening or a specific breast complaint (including, but not limited to a mass, lump, thickening or nipple discharge) should be evaluated, as indicated, in a timely manner. Providers should have procedures in place to ensure appropriate individual education and counseling, referral for further evaluation (including additional testing and biopsy) when indicated, communication and coordination with the person and other providers, and proper follow-up through the conclusion of the case.

For persons who require referral for services beyond those available through the contracted provider, contractors are encouraged, whenever possible, to refer those persons to an HHSC Breast and Cervical Cancer Services (BCCS) contractor.  Information is available at https://hhs.texas.gov/Doing-Business-HHS/Provider-Portals/Health-Services-Providers/Womens-Health-Services/Breast-Cervical-Cancer-Services.

Eligible individuals in need of treatment for biopsy-proven breast cancer may apply for coverage under the Medicaid for Breast and Cervical Cancer Program. Information is available at https://hhs.texas.gov/doing-business-hhs/provider-portals/health-services-providers/womens-health-services/breast-cervical-cancer-services/breast-cervical-cancer-treatment-information.

 

12323 References and Resources

Revision 19-0; Effective July 1, 2019

 

References

Siu, AL. Screening for breast cancer: U.S. Preventive Services Task Force Recommendation Statement.Ann Intern Med. 2016;164(4):279-296. Available at http://annals.org/article.aspx?articleid=2480757

National Comprehensive Cancer Network (2018). NCCN clinical practice guidelines in oncology: Breast cancer screening and diagnosis. Version 2.2018. Available at https://www.nccn.org/professionals/physician_gls/f_guidelines.asp#breast_screening.

Additional Reading

National Comprehensive Cancer Network (2018). NCCN clinical practice guidelines in oncology: Breast cancer risk reduction. Version 2.2018. Available at https://www.nccn.org/professionals/physician_gls/f_guidelines.asp#breast_risk.

National Comprehensive Cancer Network (2017). NCCN clinical practice guidelines in oncology: Genetic/familial high-risk assessment: Breast and ovarian. Version 1.2018. Available at https://www.nccn.org/professionals/physician_gls/f_guidelines.asp#breast_risk.

Information for Patients

National Cancer Institute. Mammograms patient information. Available at http://www.cancer.gov/types/breast/mammograms-fact-sheet.

National Cancer Institute. Breast Cancer – Patient Version. Available at http://www.cancer.gov/types/breast.

Online Provider Resources

National Cancer Institute. Breast Cancer Risk Assessment Tool. Available at http://www.cancer.gov/bcrisktool/Default.aspx.

 

12330 Sexually Transmitted Disease/Infection (STD/STI) Screening and Treatment

Revision 19-0; Effective July 1, 2019

 

The summary of cited guideline recommendations provided in this section reflect the ages of eligibility for the FPP and do not include guideline recommendations for individuals outside this range.

Screening and treatment of STDs/STIs must follow the current guidelines for screening and treatment from the Centers for Disease Control and Prevention (CDC). A risk assessment should be done for all individuals to determine what testing is indicated and documented in the medical record. Following is a brief overview of STD/STI screening recommendations (for more detailed information, go to the CDC screening links above).

 

12331 HIV Screening

Revision 19-0; Effective July 1, 2019

 

  • Contractors must provide HIV testing, either on-site or by referral.
  • If HIV testing is done, verbal or written consent should be documented in the medical record. Document if testing is indicated and the person declines.
  • All individuals age 13 to 64 should be screened at least once for HIV, using a policy that provides HIV education and allows individuals to opt out of screening, if desired. With opt-out screening, individuals are informed, prior to testing, that HIV testing will be done as part of the general consent for care and they are free to decline testing if they choose to do so. If they do not decline, the test is performed.
  • Individuals who engage in risky sexual practices or share injection drug paraphernalia should be tested annually.
  • Individuals who seek testing or treatment of STDs/STIs should be tested for HIV at the same time.
  • Contractors may provide negative HIV test results to individuals in person, by telephone, or by the same method or manner as the results of other diagnostic or screening tests. The provision of negative test results by telephone must follow procedures that address a person’s confidentiality, identification of the person and prevention counseling.
  • Contractors must always provide positive HIV test results to individuals in a face-to-face encounter with an immediate opportunity for counseling and referral to community support services. Test results must be provided by staff knowledgeable about HIV prevention and HIV testing.
  • Individuals whose risk assessment reveals high-risk behaviors should be provided directly, or referred for, more extensive risk reduction counseling by a Department of State Health Services (DSHS) HIV/STD program trained risk reduction specialist.
  • Persons with a diagnosis of HIV should be referred to a DSHS HIV/STD program contractor for treatment and monitoring.
  • To find a DSHS HIV/STD program contractor, visit DSHS HIV/STD.

 

12332 Chlamydia and Gonorrhea Testing

Revision 19-0; Effective July 1, 2019

 

  • Chlamydia and gonorrhea screening must be provided by contractors.
  • Annual chlamydia and gonorrhea screening should be provided for all sexually active women under age 25. If a pelvic examination will not be performed, as in asymptomatic women under age 21 and other women who decline a pelvic examination, screening can be performed using a nucleic acid amplification technique on a urine sample or a patient self-obtained vaginal swab.
  • Testing should also be done in older asymptomatic women with increased risk and in all symptomatic women.  Indications include, but are not limited to:
    • New or multiple sex partners;
    • A partner who has another partner;
    • Exposure to an STD/STI;
    • Symptoms or signs of cervicitis or an STD/STI;
    • History of pelvic inflammatory disease;
    • A positive test for an STD/STI in the prior 12 months; and
    • Sex work or drug use.
  • Treated individuals should be retested approximately three to four months after treatment to assess evidence of reinfection.
  • All women who are pregnant, or attempting pregnancy, should be tested.
  • Routine screening of males for chlamydia and gonorrhea is not recommended but should be considered in settings where the prevalence of infection is high, such as correctional facilities and adolescent clinics.

 

12333 Herpes Simplex Virus (HSV) Screening

Revision 19-0; Effective July 1, 2019

 

  • Routine screening of asymptomatic individuals for genital HSV infection is not recommended in the general or pregnant population.
  • Testing, counseling and treatment of symptomatic individuals (i.e., presence of genital lesions), as well as management of affected pregnant individuals, should follow current CDC guidelines.
  • The preferred tests for confirmation of the diagnosis in individuals with active genital ulcers or mucocutaneous lesions are cell culture and polymerase chain reaction (PCR) assay.
  • Type-specific serologic testing may be appropriate in some circumstances:
    • For men and women presenting for evaluation of an STD/STI (especially those who report multiple sexual partners) and persons with HIV infection;
    • For men who have sex with men and unknown HSV infection status, type-specific serologic testing may be appropriate in the evaluation of an undiagnosed genital tract infection;
    • When the diagnosis is suspected, but no lesions are present (a culture or PCR assay is not indicated if no lesions are present);
    • When the diagnosis is uncertain and virologic tests (i.e., culture and PCR) are negative in a symptomatic patient; or
    • For counseling patients regarding the risk of infection by a partner with known infection, especially during pregnancy.

 

12334 Syphilis Screening (Men and Nonpregnant Women)

Revision 19-0; Effective July 1, 2019

 

  • Men and nonpregnant women who are at increased risk of syphilis infection should undergo screening for syphilis.
  • Men who have sex with men, and men and women who are living with HIV have the highest risk for syphilis infection.
  • Other factors associated with increased prevalence of syphilis infection are a history of incarceration or commercial sex work.
  • According to 2014 surveillance data, approximately 91% of cases of syphilis occurred in men, with the highest rates in men age 20 to 29.
  • Syphilis prevalence (per 100,000 population) in the U.S. varied by race and ethnicity in 2014:
    • Black: 18.9
    • Hispanic and American Indian/Alaska Native: 7.6
    • Native Hawaiian/Pacific Islander: 6.5
    • White: 3.5
    • Asian: 2.8
  • Routine screening for syphilis in a nonpregnant population that is not at increased risk of syphilis infection is not recommended because it may yield a high false-positive rate, leading to overtreatment.

 

12335 Other Screening and Pregnant Women

Revision 19-0; Effective July 1, 2019

 

Screening for other infections and more frequent screening should be considered as appropriate based on the person’s condition, risk factors and concerns.

Pregnant Women

  • All pregnant women should undergo screening for syphilis, HIV (by an opt-out policy), and hepatitis B surface antigen as early as possible in the pregnancy.
  • Individuals under age 25 and women at increased risk should also have chlamydia and gonorrhea testing. 
  • Repeat testing in the third trimester is recommended for individuals at increased risk of new infection.

 

12336 Patient-Delivered Partner Therapy (PDPT)

Revision 19-0; Effective July 1, 2019

 

PDPT is the practice of providing therapy to the sexual partner(s) of a person being treated for chlamydia or gonorrhea without first developing a patient-clinician relationship with the partner(s). Untreated partners can reinfect treated individuals and expose others to infection.

Providers are encouraged to implement PDPT by providing individuals who are being treated for either chlamydia or gonorrhea with medications or prescriptions the partner(s) can use to be treated as well. 

Providers may not receive reimbursement for providing partner treatment under this policy to persons who have not been patients.

 

12337 References

Revision 19-0; Effective July 1, 2019

 

American College of Obstetricians and Gynecologists. Committee Opinion No. 598: The initial reproductive health visit. Obstet Gynecol (2014) 123: 1143-1147. Available at http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Adolescent_Health_Care/The_Initial_Reproductive_Health_Visit.

Branson, BM., et al. Revised recommendations for HIV testing of adults, adolescents and pregnant women in health care settings. MMWR (2006) 55(RR14): 1-17.  Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.

Centers for Disease Control and Prevention. Genital herpes. Available at http://www.cdc.gov/std/Herpes/default.htm.

Centers for Disease Control and Prevention. Pregnant women, infants and children: An opt-out approach to HIV screening. Available at http://www.cdc.gov/hiv/group/l/pregnantwomen/opt-out.html.

Centers for Disease Control and Prevention. Sexually transmitted diseases:
Treatment. Available at http://www.cdc.gov/std/treatment/default.htm.

Centers for Disease Control and Prevention. STD and HIV Screening Recommendations. Available at http://www.cdc.gov/std/prevention/screeningreccs.htm.

U.S. Preventive Services Task Force. Screening for syphilis infection in nonpregnant adults and adolescents: U.S. Preventive Services Task Force recommendation statement. JAMA (2016) 315(21): 2321-2327. Available at http://jamanetwork.com/journals/jama/fullarticle/2526645.

Expedited (Patient-Delivered) Partner Therapy (information for patients and providers):

Centers for Disease Control and Prevention. Expedited partner therapy website. Available at http://www.cdc.gov/std/ept/.

Texas Dept. of State Health Services. Expedited partner therapy website. Available at http://www.dshs.state.tx.us/hivstd/ept/default.shtm.

 

12340 Diabetes Mellitus Screening

Revision 19-0; Effective July 1, 2019

 

Who Should Be Screened for Diabetes

The criteria below apply to nonpregnant patients only.

  • Begin screening all adults at age 45.
  • Screen adults younger than age 45 who are overweight or obese (BMI greater than or equal to 25 kg/m2 [BMI greater than or equal to 23 kg/m2 for Asian Americans]) with one or more risk factor. An adult BMI calculator is available from the Centers for Disease Control and Prevention (CDC).
  • Screen overweight or obese children or adolescents (age 19 or younger) with two or more additional risk factors. To determine whether the individual is overweight or obese, see Defining Childhood Obesity and the CDC child and teen BMI calculator.
  • If screening test results are normal, retest at least every three years. Consider more frequent testing in patients with risk factors. 
  • Patients with prediabetes [impaired fasting glucose (IFG), or impaired glucose tolerance (IGT)] should be retested every year. IFG and IGT refer to laboratory values that are above the normal range but do not meet the diagnostic criteria for diabetes. Persons with these results are said to have prediabetes.
  • All women with a diagnosis of gestational diabetes in a recent pregnancy should have diabetes screening with a two-hour oral glucose tolerance test at six to 12 weeks postpartum, regardless of other risk factors.
  • All women with any history of gestational diabetes should have testing for diabetes and prediabetes at least every three years, regardless of other risk factors.

Risk Factors for Diabetes

  • High-risk race or ethnicity (e.g., Latino, African American, Asian American, Native American, Pacific Islander);
  • Diabetes in a first-degree relative;
  • Physical inactivity;
  • Women who ever had gestational diabetes or delivered a baby weighing less than nine pounds;
  • History of prediabetes: hemoglobin A1C greater than 5.7% (39 mmol/mol), IFG or IGT in previous testing;
  • HDL cholesterol less than 35 mg/dL (0.90 mmol/L) and/or serum triglyceride level greater than 250 mg/dL (2.82 mmol/L);
  • A history of polycystic ovary syndrome;
  • A diagnosis of hypertension;
  • A history of cardiovascular disease; or
  • Any other condition in which insulin resistance is common, such as severe obesity or acanthosis nigricans.

 

12341 Diagnostic Criteria

Revision 19-0; Effective July 1, 2019

 

Any one or more of the following results, confirmed on repeat testing, meets the criteria for a diagnosis of diabetes (repeat testing for confirmation is not required in the presence of unequivocal clinical hyperglycemia):

  • Fasting plasma glucose (after no caloric intake for a minimum of 8 hours) greater than or equal to 126 mg/dL (7.0 mmol/L);
  • Oral glucose tolerance test (OGTT) with a two-hour postprandial glucose level greater than or equal to 200 mg/dL (11.1. mmol/L) following a 75-g glucose load;
  • Hemoglobin A1C greater than or equal to 6.5% (48 mmol/mol). For diagnosis of type I diabetes in individuals with acute hyperglycemic symptoms, blood glucose testing is preferred; or
  • Random plasma glucose greater than or equal to 200 mg/dL (11.1. mmol/L) in the setting of a hyperglycemic crisis or classic symptoms of hyperglycemia. (Confirmation by repeat testing is not required in this setting.)
Test Criteria to Diagnose Diabetes Mellitus Comments
Fasting plasma glucose Greater than or equal to 126 mg/dL (7.0 mmol/L) After no caloric intake for a minimum of eight hours.
Oral glucose tolerance test (with a 75-g glucose load) Two-hour glucose greater than or equal to 200 mg/dL (11.1. mmol/L)  
Hemoglobin A1C Greater than or equal to 6.5% (48 mmol/mol) For diagnosis of type I diabetes in individuals with acute hyperglycemic symptoms, blood glucose testing is preferred.
Random plasma glucose Greater than or equal to 200 mg/dL (11.1. mmol/L) If this occurs in the setting of a hyperglycemic crisis or classic symptoms of hyperglycemia, confirmation by repeat testing is not required.

Table: Diagnostic Criteria for Diabetes Mellitus. All initial results should be confirmed with repeat testing.

 

12342 References and Resources

Revision 19-0; Effective July 1, 2019

 

References

American College of Obstetricians and Gynecologists (2013). Practice Bulletin No. 137: Gestational diabetes mellitus. Obstet Gynecol. 122 406-416.

American Diabetes Association. Standards of medical care in diabetes – 2018. Diabetes Care (2018); 41(Suppl. 1). Available at  http://care.diabetesjournals.org/content/41/Supplement_1.

Resources for Patients and Educators

American Diabetes Association at http://www.diabetes.org.

American Diabetes Association Diabetes Pro website (information for providers of care) at http://professional.diabetes.org.

American Diabetes Association Diabetes Educators (information and resources for both patients and educators) at http://professional.diabetes.org/diabetes-education.

Centers for Disease Control and Prevention. Adult BMI calculator. Available at http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html.

Centers for Disease Control and Prevention. BMI calculator for child and teen. Available at http://nccd.cdc.gov/dnpabmi/Calculator.aspx.

Centers for Disease Control and Prevention. Defining childhood obesity (provides definition of overweight and obesity in children and adolescents age 2 to 19, and link to BMI calculator for children and teens). Available at http://www.cdc.gov/obesity/childhood/defining.html.

National Diabetes Education Initiative (patient education handouts and links to professional resources) at http://www.ndei.org

National Institute of Diabetes and Digestive Diseases. National Diabetes Education Program (resources for patients and educators). Available at http://www.niddk.nih.gov/health-information/health-communication-programs/ndep/pages/index.aspx.

National Heart, Lung and Blood Institute Aim for a Healthy Weight at https://www.nhlbi.nih.gov/health/educational/lose_wt.

 

12350 Hypertension Screening

Revision 19-0; Effective July 1, 2019

 

All individuals, including those with hypertension, should be advised to adhere to a healthy lifestyle as described in Section 12400, Healthy Lifestyle Intervention.

Classification of BP and Diagnosis of Hypertension

In the United States, high blood pressure (BP) is the second leading cause of preventable death after cigarette smoking and is the most important modifiable risk factor for death due to cardiovascular disease. Because hypertension is generally asymptomatic, it is important that all persons be screened at least annually for elevated BP.

The following table provides guidance on diagnosis of hypertension in adults. Recent guidelines emphasize greater reliance on home BP monitoring to aid in the diagnosis of hypertension when clinic readings are high normal, borderline high or elevated. It is generally agreed that clinic BP measurements are often higher than home BP measurements, particularly in the higher ranges of BP.

BP (mm Hg) Category
Less than 120/80 Normal
120-129/Less than 80 Elevated
130-139/80-89 Stage 1 hypertension
Greater than or equal to 140/90 Stage 2 hypertension

Measurement of BP

  • For diagnosis of hypertension, BP readings should be based on the average of accurate measurements taken on two or more occasions using proper technique.
  • Ambulatory or home BP monitoring should be performed to confirm the diagnosis of hypertension.
  • Adults not being treated for hypertension who have office BP readings of 130/80 to 160/100 mm Hg should be screened for white coat hypertension (WCH), high BP in the clinic but normal BP outside the clinic, using ambulatory or home BP monitoring.
  • Periodically monitor adults with WCH using ambulatory or home BP monitoring to assess for development of sustained hypertension.
  • Adults not being treated for hypertension who have office BP readings of 120/75 to 129/79 mm Hg consistently should be screened for masked hypertension (normal BP in the clinic but high BP outside the clinic) using ambulatory or home BP monitoring.

Instructions for Home BP Monitoring

  • Patients should receive instruction for home BP monitoring, including interpretation of results under medical supervision.
  • An automated validated device should be used, preferably with the ability to store readings in memory. 
  • Correct cuff size should be verified, and the patient should be instructed to measure BP in the arm with the higher reading if a significant difference is observed between arms.
  • Instruct the patient to rest quietly for at least five minutes and avoid exercise, caffeine, and smoking for at least 30 minutes before taking BP.
  • Instruct the patient to sit upright in a straight-backed chair with feet flat on the floor, legs uncrossed, and the arm supported on a flat surface with the upper arm at heart level.
  • The bottom of the cuff should sit directly above the antecubital fossa.
  • Two readings, taken one minute apart, should be done twice daily, in the morning before taking any medications, and in the evening before eating supper. Measurements should be done daily, for one week before a clinic visit.
  • Monitors with stored memory should be brought to any clinic appointments.
  • Clinical decision making should be based on the average of readings taken on two or more occasions.

Nonpharmacologic Intervention

All patients, regardless of BP category should receive instruction in healthy lifestyle habits, with regular reinforcement of teaching. 

  • Weight loss should be advised for adults who are overweight or obese.
  • Persons with elevated BP or hypertension should adopt a heart-healthy diet (e.g., DASH diet) to reduce BP.
  • Sodium intake should be reduced.
  • Potassium intake should be increased, preferably by dietary modification.
  • Physical activity should be increased using a structured exercise program.
  • Alcohol intake should be avoided or moderated (less than or equal to one standard drink daily for women, less than or equal to two 2 standard drinks daily for men).

 

12351 References and Resources

Revision 19-0; Effective July 1, 2019

 

References

Carey, R. M., Whelton, P. K. (2018). Prevention, detection, evaluation and management of high blood pressure in adults: Synopsis of the 2017 American College of Cardiology/American Heart Association hypertension guideline. Ann Intern Med, 168(5), 351-358. Available at http://annals.org/aim/fullarticle/2670318/prevention-detection-evaluation-management-high-blood-pressure-adults-synopsis-2017.

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., Wright, J. T. (2017). ACC/AHA/AAPA/ABC/ACPM/AGS/APha/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation and management of high blood pressure in adults. Hypertension, 71(6), e13-e115. Available at http://hyper.ahajournals.org/content/71/6/e13.long.

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., Wright, J. T. (2017). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APha/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation and management of high blood pressure in adults. Executive Summary: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol, 71(19), 2199-2269. Available at https://www.sciencedirect.com/science/article/pii/S073510971741518X?via%3Dihub.

Resources for Patients and Educators

American Heart Association. High blood pressure. Provides information on the meaning and importance of high blood pressure, risks for, and prevention of, high blood pressure, blood pressure monitoring and treatment of high blood pressure. Available at http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/High-Blood-Pressure_UCM_002020_SubHomePage.jsp.

National Heart, Lung and Blood Institute. Description of high blood pressure. Provides a plain language discussion of the prevention, diagnosis and treatment high blood pressure. Available at http://www.nhlbi.nih.gov/health/health-topics/topics/hbp.

Resources for Providers

American Society of Hypertension. Hypertension Guidelines at http://www.ash-us.org/About-Hypertension/Hypertension-Guidelines.aspx.

 

12360 High Cholesterol Screening

Revision 19-0; Effective July 1, 2019

 

The summary of cited guideline recommendations provided in this section reflect the ages of eligibility for the FPP and do not include guideline recommendations for individuals outside this eligibility range.

The diagnosis and treatment of elevated blood cholesterol is a complex subject and a complete discussion is beyond the scope of this manual. For more information, providers are referred to Section 12362, References and Resources, and relevant textbooks.

Rationale for Cholesterol Screening

Evidence shows that a healthy lifestyle (following a heart healthy diet, maintaining a healthy weight, regular exercise and avoidance of tobacco products) reduces the risk of cardiovascular disease. In certain persons with specific risk factors, cholesterol-lowering medications (i.e., statins) can further reduce the risk of an adverse health event. Measurement of blood cholesterol is a component of the individual risk assessment in some patients.

Who Should Be Screened for High Cholesterol

  • All men age 35 and older;
  • Men age 20 through35 years of age with increased risk for coronary heart disease; and
  • Women age 20 and older with increased risk for coronary heart disease (CHD).

No recommendation is made regarding routine screening in men age 20 through 35 or in women age 20 or older without increased risk of CHD.

Risk Factors

Increased risk of CHD is defined by the presence of any one of the risk factors below.  Greater risk results from the presence of multiple risk factors.

  • Diabetes;
  • Personal history of previous CHD or noncoronary atherosclerosis;
  • Family history of cardiovascular disease in men before age 50 and in women before age 60;
  • Tobacco use;
  • Hypertension; or
  • Obesity (body mass index great than or equal to 30 kg/m2).

Screening Frequency

The optimal interval for screening is uncertain. Reasonable options include every five years, shorter intervals for people who have lipid levels close to those warranting therapy, and longer intervals for those not at increased risk who have had repeatedly normal lipid levels.

An age at which to stop screening has not been established.

Screening Method

The preferred screening test for elevated cholesterol is the serum lipid panel (total cholesterol, high-density lipoprotein [HDL] cholesterol, and low-density lipoprotein [LDL] cholesterol) in the fasting or non-fasting state. If non-fasting results are used, only the total cholesterol and HDL cholesterol are reliable. Abnormal screening results should be confirmed by a repeat sample on a separate occasion, and the average of both results should be used for risk assessment.

 

12361 Evaluation of Screening Results

Revision 19-0; Effective July 1, 2019

 

Results of the lipid profile should be interpreted in the context of the individual’s risk factors and 10-year estimated risk of atherosclerotic cardiovascular disease (ASCVD), defined as acute coronary syndrome, myocardial infarction, stable or unstable angina, stroke, transient ischemic attack, coronary or other arterial revascularization procedure, or atherosclerotic peripheral arterial disease. A risk calculator for 10-year ASCVD risk is available from the American College of Cardiology and American Heart Association.

Studies have shown a benefit of statin therapy in individuals with the following risk profiles:

  • All individuals with clinical ASCVD, regardless of lipid profile results;
  • Any individual with LDL cholesterol greater than or equal to 190 mg/dL;
  • Individuals age 40 or older with diabetes and LDL cholesterol greater than or equal to 70-189 mg/dL and no clinical ASCVD;
  • Individuals age 40 or older with diabetes and LDL cholesterol 70-189 mg/dL and no clinical ASCVD; or
  • Individuals of any age without diabetes or clinical ASCVD, with LDL cholesterol 70-189 mg/dL and 10-year ASCVD risk greater than or equal to 7.5%.

 

12362 References and Resources

Revision 19-0; Effective July 1, 2019

 

Stone N.J., et al. 2013 ACC/AHA Guidelines on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation (2014). 129 (25 Suppl. 2): S1-S45 Available at https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.full.

National Heart, Lung and Blood Institute. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Cholesterol in Adults (Adult Treatment Panel III). NIH Publication No. 01-3670, May 2001. Available at http://www.nhlbi.nih.gov/files/docs/guidelines/atp3xsum.pdf.

U.S. Preventive Services Task Force. The Guide to Clinical Preventive Services, Lipid Disorders in Adults (2014), Page 45. Available at http://www.ahrq.gov/sites/default/files/publications/files/cpsguide.pdf.

Further Reading

Pursnani A, et al. Guideline-based statin eligibility, coronary artery calcification and
cardiovascular events. JAMA (2015) 314:134-141. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4754085/.

Resources for Providers

ASCVD Risk Estimator from the American College of Cardiology. Provides an estimate of the 10-year risk of developing ASCVD. Available at http://tools.acc.org/ASCVD-Risk-Estimator/.

 

12370 Postpartum Depressing Screening

Revision 19-0; Effective July 1, 2019

 

Prevalence and Risk Factors for Postpartum Depression

As many as 80% of new mothers experience a brief episode of the “baby blues” which may last up to two weeks. Approximately 5-25% of new mothers will experience postpartum depression that warrants intervention. It typically begins in the first four to six weeks after birth of the infant but may develop any time in the first year. 

Risk factors for postpartum depression include the following:

  • Lack of social support;
  • Symptoms of depression (especially in the third trimester) or anxiety during the pregnancy;
  • Prior psychiatric illness or poor mental health, especially prior postpartum depression;
  • Family history of depression, anxiety or bipolar disorder;
  • Low socio-economic status or low educational level;
  • Poor income or unemployment;
  • Poor relationship with the partner or father of the baby;
  • A negative attitude toward the pregnancy;
  • A recent stressful life event or perceived stress;
  • Intention to return to work;
  • A history of bothersome premenstrual syndrome;
  • A history of physical, sexual or psychological abuse or domestic violence;
  • Stress related to child care issues;
  • Medical illness or prematurity in the infant;
  • A temperamentally difficult infant; or
  • Immigrant from another country.

Common signs and symptoms of postpartum depression include the following (some or none of these symptoms may be apparent):

  • Difficulty sleeping even when the baby is sleeping;
  • Tearfulness, prone to crying;
  • Excessive worrying about the baby;
  • Excessive anxiety;
  • Feelings of guilt, such as the feeling that she is not a good mother;
  • Flat affect; or
  • Poor appetite.

Screening for Postpartum Depression

Providers are encouraged to review The Texas Clinician’s Postpartum Depression Toolkit for a more detailed review of screening for postpartum depression.

Because postpartum depression can be a serious and sometimes life-threatening condition, all new mothers should have screening for postpartum depression at the postpartum visit. For those who screen negative, repeat screening should be considered at a later visit or when the mother takes her baby in for a checkup.

A standardized self-administered screening tool with review and follow-up questions in a face-to-face interview with the provider will ensure consistency and efficiency in the screening process. The following postpartum depression screening tools are available online and have been validated for use in postpartum patients:

To ensure that all patients are screened without undue interruption of clinic workflow, a convenient approach to screening is the following:

  • Give each postpartum woman a screening tool to complete while she waits for her visit with the provider.
  • Score the tool and assess whether the screen is positive or negative:
    • EPDS: A score of 10 or more suggests depressive symptoms; a score of 13 or more indicates a high likelihood of major depression; a score of one or more on Question 10 is an automatic positive screen because it indicates possible suicidal ideation and should be addressed appropriately.
    • PHQ-9: A score of 10 or more indicates a high risk of having or developing depression; a score of two or more on Question 9 is an automatic positive screen because it indicates possible suicidal ideation and should be addressed appropriately.
    • PDSS Full form: A score of 60 or more suggests depressive symptoms; a score of 81 or more indicates a high likelihood of major depression; a score of 6 or more on the SUI (suicidal thoughts) subscale is an automatic positive screen because it indicates possible suicidal ideation and should be addressed appropriately.
    • PDSS Short form: A score of 14 or more indicates a high risk of major depression; a score of two or more on Question 7 is an automatic positive screen because it indicates possible suicidal ideation and should be addressed appropriately.
  • The provider should review the screen and discuss it with the woman and ask follow-up questions to evaluate her risk of postpartum depression.

 

12371 Referral for Treatment

Revision 19-0; Effective July 1, 2019

 

Individuals in need of treatment for postpartum depression should be referred to a provider of behavioral health services. Providers must have arrangements in place for appropriate referral of individuals to behavioral health providers in their area. For information on local behavioral health care providers, refer to the website of the Office of Mental Health Coordination, Texas Health and Human Services, or call 211.

Coding for Postpartum Depression Services

The following Current Procedural Terminology (CPT) codes are covered under the FPP:

99201 99202 99203 99204 99205
99211 99212 99213 99214 99215
90791 90792      



12372 References and Resources

Revision 19-0; Effective July 1, 2019

 

American College of Obstetricians and Gynecologists Committee Opinion No. 630. Screening for perinatal depression. Obstet Gynecol (2015). 125: 1268-1271.  Available at http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Screening-for-Perinatal-Depression.

Hirst K.P. and Moutier C.Y. Postpartum major depression. American Family Physician (2010). 82: 926-933. Available at http://www.aafp.org/afp/2010/1015/p926.html.

Norhayati M.N., et al. Magnitude and risk factors for postpartum symptoms: A literature review. J. Affect Disord. (2015). 175: 34-52.

O’Connor E, et al. Primary care screening for and treatment of depression in pregnant and postpartum women: Evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA (2016). 315: 388-406.

Resources for Patients and Providers

American Academy of Family Physicians. Postpartum Depression webpage, information for patients and providers on postpartum depression. Available at http://familydoctor.org/familydoctor/en/diseases-conditions/postpartum-depression.html.

American Academy of Family Physicians. Postpartum Depression Action Plan. Available at http://familydoctor.org/familydoctor/en/diseases-conditions/postpartum-depression/treatment/postpartum-depression-action-plan.html.

Office of Mental Health Coordination website, Texas Health and Human Services, provides links to information for providers and patients in Texas on a variety of behavioral health topics, and a link to the Substance Abuse and Mental Health Services Administration (SAMHSA) behavioral health treatment services locator.  Available at http://mentalhealthtx.org/.

STEP-PPD Support and training to enhance primary care for postpartum depression website. Provides links to resources, including postpartum depression screening tools, online training, case studies, classroom materials, Clinician’s Pocket Guide and other materials. Available at  https://step-ppd.com/.

Texas Health and Human Services, the Texas Clinician’s Postpartum Depression Toolkit. Contains a review of the diagnosis and treatment of postpartum depression for the primary care provider, including a section on covered services, coding and billing for services provided under Texas state health care programs. Available at  https://www.healthytexaswomen.org/provider-resources#family-planning-program.

 

12380 Suicide Risk Screening

Revision 19-0; Effective July 1, 2019

 

Any individual with a positive screen based on responses to questions related to suicide risk, and any individual who expresses suicidal thoughts or ideation, must be evaluated immediately for suicide risk. If the individual is felt to be acutely at risk of suicide, she must be referred for emergent evaluation and/or hospitalization, as indicated.

 

12400 Healthy Lifestyle Intervention

Revision 19-0; Effective July 1, 2019

 

All individuals should receive a health risk survey, at least annually, to determine areas where lifestyle modifications might reduce the risk of future disease and improve health outcomes and quality of life.

Counseling on Healthy Lifestyle Choices

  • All individuals should be advised not to smoke or to use tobacco products, and to avoid exposure to second-hand smoke as much as possible. Those who use tobacco products should be advised to quit and be assessed for their readiness to do so at each encounter.
  • Individuals should be counseled on healthy eating patterns and offered access to relevant information.
  • Individuals should be advised to limit their salt intake.
  • Individuals should be advised to engage in at least 30 minutes of physical activity or resistance training, tailored to their individual health condition and risks, at least three days per week with no more than two consecutive inactive days. More frequent and longer duration (e.g., 60 minutes per day) activity is better.

The following provides details for why and how to achieve some of these goals.

Diet and Nutrition

There is strong evidence that nutrition plays an important role in our risk of disease. Dietary patterns that emphasize a lower percentage of total calories from fat, reduced amounts of saturated fats, and reduced sodium intake while achieving and maintaining a healthy body weight have been shown to reduce the risk of cardiovascular disease, the most common cause of death in both men and women in the United States. No single diet has been shown to be the best and providers should counsel individuals on a variety of healthy eating patterns tailored to their health and cultural background, while preserving the pleasure of meals and eating.

Healthy Dietary Patterns

Two dietary patterns that have been shown to improve some measures of cardiovascular risk are the Dietary Approaches to Stop Hypertension (DASH) and Mediterranean (MED) diets. Both dietary patterns emphasize reduced saturated fat and red meat, increased fiber, vegetables, fruits, fish, oils and nuts, while allowing wide freedom of food choices to accommodate eating preferences and cultural differences among individuals.

The MED diet emphasizes:

  • Increased servings of fruits (particularly fresh fruits), vegetables (particularly green and root vegetables), whole grains (such as whole-grain breads, rice, pasta and cereals), and fatty fish (which are rich in omega-3 fatty acids);
  • Reduced amounts of red meat (emphasizing lean meats when meat is eaten);
  • Substituting lower fat or fat-free dairy products for higher fat options; and
  • Using oils (such as olive or canola), nuts (such as walnuts, almonds or hazelnuts), or margarines containing flaxseed or rapeseed oil, in place of butter and other saturated fats.

The DASH diet is:

  • High in vegetables, fruits, low-fat or fat-free dairy products, whole grains, poultry, fish, legumes and nuts;
  • Low in sweets, sugar-sweetened beverages and red meats; and
  • Lower in total fat and saturated fat than a typical American diet.

Dietary counseling on healthy eating patterns, such as those described above, provided as a routine part of an individual encounter has been shown to reduce blood pressure in those with type 2 diabetes or risk factors for cardiovascular disease, including those with mild untreated hypertension. For individuals with normal or modestly elevated cholesterol, regardless of gender or ethnicity, following a DASH dietary pattern can reduce low-density lipoprotein cholesterol (LDL cholesterol) and high-density lipoprotein cholesterol (HDL cholesterol). Following a DASH dietary pattern can reduce blood pressure in all individuals, regardless of age, sex and ethnicity, including those with mild untreated hypertension.

Salt Intake

There is strong evidence that reducing sodium (salt) intake reduces blood pressure in individuals with normal blood pressure, as well as those with mild to moderate hypertension, regardless of sex, ethnicity and age. This holds true even if no other dietary changes are made. Therefore, some individuals who consider the dietary patterns described above too drastic a change can reduce their blood pressure just by lowering their salt intake. Those who adopt a DASH dietary pattern and reduce their salt intake can lower their blood pressure even more. All individuals should receive advice to limit their salt intake and be counseled on ways to do so.

Cholesterol

Despite much public attention given to cholesterol in the diet as a cause of poor health, there has been very little research on the effect of reducing dietary cholesterol on the risk of future disease. Therefore, no recommendation can be made to counsel individuals specifically on dietary cholesterol intake.

Physical Activity

Regular aerobic physical activity (e.g., walking, jogging, dancing, swimming, water-walking, gardening, climbing stairs and even house cleaning) and resistance training (e.g., working with light weights or elastic bands) can reduce the risk of serious disease by lowering LDL cholesterol and blood pressure. Individuals should be encouraged to engage in at least 30 minutes of an activity they enjoy, suitable to their current health status and risk, at least three times a week with no more than two consecutive inactive days. More intensive physical activity (e.g., up to 60 minutes at a setting, more sessions per week), for those whose health status permits, offer more benefit.

 

12410 References and Information

Revision 19-0; Effective July 1, 2019

 

Reference

National Heart, Lung and Blood Institute. Lifestyle interventions to reduce cardiovascular risk: Systematic Evidence Review from the Lifestyle Work Group (2013). Available at http://www.nhlbi.nih.gov/health-pro/guidelines/in-develop/cardiovascular-risk-reduction/lifestyle.

Information for Patients and Educators

American Heart Association, Healthy Eating. Provides information on food choices, recipes, how to eat healthy when dining out and how to shop for groceries with a focus on healthy eating. Available at http://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/Healthy-Eating_UCM_001188_SubHomePage.jsp.

American Heart Association, Get moving! Easy tips to get active. Provides information on physical activity and fitness. Available at http://www.heart.org/HEARTORG/HealthyLiving/PhysicalActivity/Physical-Activity_UCM_001080_SubHomePage.jsp.

American Heart Association, Sodium and Salt. Provides information on ways to reduce dietary salt intake. Available at http://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/Nutrition/Sodium-and-Salt_UCM_303290_Article.jsp#.WThZ4-v1DRY.

Mayo Clinic, Healthy diets. Available at http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/basics/healthy-diets/hlv-20049477.

Mayo Clinic, DASH diet: Healthy eating to lower your blood pressure. Available at http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/dash-diet/art-20048456.

Mayo Clinic, DASH diet recipes. Available at http://www.mayoclinic.org/healthy-lifestyle/recipes/dash-diet-recipes/rcs-20077146.

Mayo Clinic, Mediterranean diet recipes. Available at http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/mediterranean-diet-recipes/art-20046682.

 

12500 Perinatal Clinical Policy

Revision 19-0; Effective July 1, 2019

 

Prenatal services should be provided based on American College of Obstetricians and Gynecologists (ACOG) guidelines.

Components of Initial Prenatal Interventions/Screening

Prenatal Visit – The initial encounter with a pregnant woman includes a complete history, physical examination, assessment, planning, treatment, counseling and education (referral as indicated), routine prenatal laboratory tests and additional laboratory tests as indicated by history, physical exam and/or assessment.

Components of Return Visit Interventions/Screening

Return Prenatal Visit – The follow-up prenatal visit includes interval history, physical examination, risk assessment, medical services, nutritional counseling, psychosocial counseling, family planning counseling and client education regarding maternal and child health topics. Hemoglobin and/or hematocrit, and urinalysis for protein and glucose are also included.

 

12510 Perinatal Histories

Revision 19-0; Effective July 1, 2019

 

Prenatal Visit

The comprehensive medical history documented at the initial prenatal visit must
at least address the following:

  • current health status, including acute and chronic medical conditions, if any;
  • significant past illnesses, including hospitalizations;
  • previous surgeries and biopsies;
  • blood transfusions and other exposure to blood products;
  • mental health history (e.g., depression, anxiety);
  • current medications, including prescription, over the counter (OTC) as well as complementary and alternative medicines (CAMs);
  • allergies, sensitivities or reactions to medicines and other substances (e.g. latex, seafood);
  • immunization status/assessment, including rubella status;
  • reproductive health history;
  • pertinent sexual behavior history, including family planning practices (i.e., past contraceptive use), number of partners and gender of sexual partners;
  • sexually transmitted infections (STIs) [including hepatitis B and C], and HIV history, risks and exposure;
  • pertinent partner history, including injectable drug use and number of partners;
  • menstrual history, including last normal menstrual period;
  • obstetrical history, detailed;
  • gynecological and urological conditions;
  • cervical cancer screening history (date and results of last Pap test or other cervical cancer screening test, and note any abnormal results and treatment); and
  • social history/health risk assessment (HRA) including:
    • home environment, to include living arrangements;
    • family dynamics with assessment for family violence (including safety assessment, when indicated) [Mandated by Texas Family Code, Chapter 261 and Rider 19];
    • tobacco/alcohol/recreational drug use/abuse and/or exposure;
    • drug dependency (including type, duration, frequency, route);
    • nutritional history;
    • occupational hazards or environmental toxin exposure;
    • ability to perform activities of daily living (ADLs); and
    • risk assessment including, but not limited to:
      • diabetes;
      • heart disease;
      • intimate partner violence;
      • other physical or sexual abuse;
      • human trafficking;
      • injury;
      • malignancy;
      • injury;
      • malignancy;
  • family history, including genetic conditions; and
  • review of systems with pertinent positives and negatives documented in the health record.

Return Prenatal Visits

The interval history includes:

  • symptoms of infections;
  • symptoms of preterm labor;
  • headaches or visual changes;
  • fetal movement (more than 18 weeks); and
  • family violence screening (repeat more than 28 weeks). 

 

12520 Physical Assessments

Revision 19-0; Effective July 1, 2019

 

All initial and routine prenatal visits must include an appropriate physical exam according to the purpose of visit and week of gestation. For any portion of the examination that is deferred, the reason(s) for deferral must be documented in the client health record.

Initial Prenatal Visit

  • height measurement;
  • weight measurement, with documentation of pre-pregnancy weight and
    assessment for underweight, overweight and obesity;
  • body mass index (BMI);
  • blood pressure evaluation;
  • cardiovascular assessment;
  • clinical breast exam;
  • visual inspection of external genitalia and perianal area;
  • pelvic exam, including estimate of uterine size (by bimanual exam for gestational age less than or equal to 14 weeks or by fundal height for gestational age equal to or more than 14 weeks);
  • fetal heart rate for gestational age greater than 12 weeks; and
  • other systems, as indicated by history and health risk assessment. (e.g., evaluation of thyroid, lungs and abdomen).

Return Prenatal Visits

  • weight measurement;
  • blood pressure evaluation;
  • uterine size/fundal height;
  • fetal heart rate (more than 12 weeks);
  • fetal lie/position (more than 30 weeks); and
  • other systems, as indicated by history or other findings.

 

12530 Laboratory and Diagnostic Tests

Revision 19-0; Effective July 1, 2019

 

All initial and return prenatal visits must include appropriate laboratory and diagnostic tests, as indicated by weeks of gestation and clinical assessment. Contractors must have written plans to address laboratory and other diagnostic test orders, results and follow-up to include:

  • tracking and documentation of tests ordered and performed for each patient;
  • tracking of test results and documentation in patient records; and
  • mechanism to address abnormal results, facilitate continuity of care and assure confidentiality, adhering to HIPAA regulations (i.e., making results and interventions accessible to the delivering hospital, facility or provider).

Initial Prenatal Visit Laboratory and Diagnostic Tests

  • blood type, Rh and antibody screen; and
  • sexually transmitted infection testing, as indicated by risk assessment, history and physical exam, and the following:
    • chlamydia and gonorrhea testing should be done on all patients age 25 or younger and older individuals at increased risk of infection, even if symptoms are not present;
    • Hepatitis B Antigen (HbsAg) [Mandated by Health and Safety Code 81.090]; and
    • HIV, unless declined by the person, who must then be referred to anonymous testing [Mandated by Health and Safety Code 81.090]

Review CDC’s revised recommendations for HIV testing for adults and pregnant women:

  • syphilis serology [Mandated by Health and Safety Code 81.090];
  • hemoglobin and/or hematocrit;
  • rubella serology or positive immune status/immunization documented in chart;
  • cervical cancer screening test (e.g., Pap test) for women age 21 and older, if indicated;
  • hemoglobinopathy screening, as indicated;
  • urine culture;
  • TB skin test, as indicated by risk assessment, history or physical exam (see the Heartland National TB Center algorithm for pregnant individuals http://www.heartlandntbc.org/assets/products/evaluation_of_pregnant_patient_at_risk_for_tb.pdf);
  • ultrasound, as clinically indicated; and
  • other laboratory and diagnostic tests, as indicated by risk assessment, history and physical exam.

 

12531 ACOG/ACS/ASCCP/ASCP Cervical Cancer Screening Guidelines 

Revision 19-0; Effective July 1, 2019

 

  • Cervical cancer screening begins at age 21;
  • Cervical cytology (Pap smear) alone, with reflex human papillomavirus (HPV) testing when cytology reveals atypical squamous cells of undetermined significance (ASCUS), every three years for women between age 21 and 29;
  • Women age 30 and older should have co-testing with cervical cytology and HPV testing every five years (preferred) or cervical cytology testing alone (with reflex HPV testing for ASCUS) every three years; and
  • Both liquid-based and conventional methods of cervical cytology are acceptable for screening.

Women with special circumstances, who are considered high-risk [e.g. HIV positive, immunosuppressed or were exposed to Diethylstilbestrol (DES) in utero] may be screened more frequently as determined by the clinician.

Individuals already following a plan of care/algorithm may continue with that plan of care/algorithm until completed and they return to routine screening. Once the person returns to routine screening, follow the guidelines above.

 

12532 Return Prenatal Visits Laboratory and Diagnostic Tests

Revision 19-0; Effective July 1, 2019

 

  • Fetal aneuploidy screening appropriate for the gestational age at the time of testing should be offered to all patients with appropriate counseling;
  • diabetes screen (24 through 28 weeks);
  • Glucose tolerance test (GTT) for abnormal diabetic screen;
  • antibody screen for Rh negative individuals, not previously known to be sensitized, between 24 through 28 weeks (if negative, repeat Anti-D immune globulin at about 28 weeks and if positive, refer to specialist in high-risk obstetrics for evaluation of possible maternal Rh-D alloimmunization);
  • hemoglobin and/or hematocrit (recommended recheck between 32 and 36 weeks);
  • group B streptococcus screen, between 35 and 37 weeks if using screened-based approach [see the Centers for Disease Control and Prevention (CDC) revised 2002 recommendations to prevent perinatal transmission of Group B Streptococcus (GBS) infection to the neonate on the CDC web site at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5111a1.htm];
  • ultrasound, as clinically indicated;
  • non-stress test (NST) to assess fetal well-being, as clinically indicated;
  • biophysical profile (BPP)/fetal biophysical profile (FBPP) to assess fetal wellbeing, as clinically indicated; and
  • other laboratory and diagnostic tests as indicated by risk assessment, history and physical exam. 

 

12533 Ultrasounds

Revision 19-0; Effective July 1, 2019

 

Obstetrical ultrasounds will be reimbursed when clinically indicated, including the
following:

  • estimation of gestational age for women with uncertain clinical dates;
  • verification of dates for women who had a previous cesarean delivery;
  • vaginal bleeding of undetermined origin;
  • suspected multiple gestation;
  • significant uterine size/clinical dates discrepancy;
  • pelvic mass;
  • suspected ectopic pregnancy;
  • suspected fetal death;
  • suspected uterine abnormality;
  • intrauterine contraceptive device localization;
  • abnormal alpha-fetoprotein value;
  • follow-up observation of identified fetal anomaly;
  • follow-up evaluation of placental location for suspected placenta previa;
  • history of previous congenital anomaly;
  • serial evaluation of fetal growth in multifetal gestation;
  • evaluation of fetal condition in late registrants for prenatal care; and
  • other conditions associated with possible adverse fetal outcome.

Complete ultrasound – A complete evaluation of the pregnant uterus, to include fetal number, viability, presentation, dating measurements, complete anatomical survey, placental localization characterizations and amniotic fluid assessment.

Complete ultrasound for confirmed multiple gestation – A complete evaluation of the pregnant uterus that includes viability, presentation, dating measurements, complete anatomical survey, placental localization characterizations and amniotic fluid assessment.

Follow-up or limited ultrasound – A brief, more limited evaluation of the pregnant uterus that may follow a previous complete exam, be it an initial exam prior to 12 weeks or an initial exam at 12 weeks which is limited in scope. It includes fetal number, viability, presentation, dating measurements, limited anatomic assessment, placental localization and characterization, and amniotic fluid assessment.

 

12534 Repeat D Antibody Test

Revision 19-0; Effective July 1, 2019

 

For all unsensitized D-negative women at 24 through 28 weeks of gestation, followed by the administration of a full dose of D immunoglobulin if they are antibody negative. If the father is known with certainty to be Rh D-negative, this may be deferred.

 

12535 Special Procedures

Revision 19-0; Effective July 1, 2019

 

Nonstress test (NST) – Fetal well-being assessment to be performed in the presence of identified risk factors, as indicated, once a viable gestational age has been reached. It may be billed as often as the provider deems the procedure to be medically necessary.

Biophysical Profile (BPP)/Fetal Biophysical Profile (FBPP) – Fetal well-being
assessment to be performed in the presence of identified risk factors, as indicated, once a viable gestational age has been reached. It may be billed as often as the provider deems the procedure to be medically necessary.

 

12540 Education and Counseling Services

Revision 19-0; Effective July 1, 2019

 

Contractors must have written plans for individual education that ensure consistency and accuracy of information provided, and that identify mechanisms used to ensure client understanding of the information.

Education and counseling must be:

  • documented in the client health record;
  • appropriate to the person’s age, level of knowledge and socio-cultural background; and
  • presented in an unbiased manner.

Education and counseling during the initial prenatal visit, based on health history, risk assessment and physical exam, must cover the following:

  • nutrition and weight gain counseling;
  • family and intimate partner violence/abuse;
  • human trafficking;
  • physical activity and exercise;
  • sexual activity;
  • environmental or work hazards;
  • travel;
  • tobacco cessation;
  • alcohol use;
  • substance abuse;
  • breastfeeding;
  • when and where to obtain emergency care;
  • risk factors identified during visit;
  • anticipated course of prenatal care;
  • HIV and other prenatal tests;
  • injury prevention, including seat belt use;
  • cocooning infants/children against pertussis (immunization of family members and potential caregivers of infant);
  • toxoplasmosis precautions;
  • referral to Women, Infants and Children (WIC);
  • use of medications (including prescription, over the counter (OTC), and
    complementary/alternative medicines (CAMs);
  • information on parenting and postpartum counseling (Mandated by Chapter 161, Health and Safety Code, Subchapter T); and
  • other education and counseling as indicated by risk assessment, history and physical exam.

Education and counseling during the return prenatal visits, should be appropriate to weeks’ gestation and be based on health history, risk assessment and physical exam, including but not limited to:

  • signs and symptoms of preterm labor beginning in second trimester;
  • signs and symptoms of labor as the patient nears term gestation;
  • warning signs and symptoms of pregnancy induced hypertension (PIH);
  • selecting a provider for the infant; and
  • postpartum family planning.

Tobacco Assessment and Quit Line Referral – All women receiving prenatal services should be assessed for tobacco use. Women who use tobacco should be referred to tobacco quit lines. The Texas American Cancer Society Quit Line is 877-YES-QUIT or 866-228-4327 (hearing impaired). The assessment and referral should be performed by agency staff and documented in the clinical record.

Information for Parents of Newborns Requirement Chapter 161, Health and Safety Code, Subchapter T, requires hospitals, birthing centers, physicians, nurse-midwives and midwives who provide prenatal care to pregnant women during gestation or at delivery, to provide the woman and the father of the infant, or other adult caregiver for the infant, with a resource pamphlet that includes information on postpartum depression, shaken baby syndrome, immunizations, newborn screening, pertussis and sudden infant death syndrome. In addition, it must be documented in the person's chart that she received this information and the documentation must be retained for a minimum of five years. It is recommended that the information be given twice, once at the first prenatal visit and again after delivery.

Information for Parents of Children Chapter 161, Health and Safety Code,
Subchapter T, also requires hospitals, birthing centers, physicians, nurse-midwives and midwives who provide prenatal care during gestation or at delivery to pregnant women on Medicaid, to provide the woman and the father of the infant, or other adult caregiver for the infant, with a resource guide that includes information relating to the development, health and safety of a child from birth until age five. The resource guide must provide information about medical home, dental care, effective parenting, child safety, importance of reading to a child, expected developmental milestones, health care and other resources available in the state, and selecting appropriate child care.

Provision of Information about Umbilical Cord Blood Donation Requirement Chapter 162, Health and Safety Code, Subtitle H, requires that a physician, or other person permitted by law to attend a pregnant woman during gestation or at delivery of an infant, shall provide the woman with an informational brochure before the third trimester of the woman’s pregnancy or as soon as reasonably feasible, that includes information about the uses, risks and benefits of cord blood stem cells for a potential recipient, options for future use or storage of cord blood, the medical process used to collect cord blood, any costs that may be incurred by a pregnant woman who chooses to donate or store cord blood after delivery and average cost of public and private storage. The brochure is available on the DSHS website or can be ordered from the DSHS literature warehouse. https://www.dshs.state.tx.us/pdf/umbilical_brochure_(2).pdf

Education and counseling during postpartum visits should include, but not be limited to:

  • physiologic changes;
  • signs and symptoms of common complications;
  • care of the breast;
  • care of perineum and abdominal incision, if indicated;
  • physical activity and exercise;
  • breastfeeding/infant feeding;
  • resumption of sexual activity;
  • family planning/contraception;
  • preconception counseling; or
  • depression/postpartum depression.

 

12541 Referral and Follow-up

Revision 19-0; Effective July 1, 2019

 

Agencies must have written policies and procedures for follow-up on referrals that are made because of abnormal physical examination or laboratory test findings. These policies must be sensitive to patients’ concerns for confidentiality and privacy and must follow state or federal requirements for transfer of health information.

For services determined to be necessary, but which are beyond the scope of the agency, patients must be referred to other providers for care. (Whenever possible, patients should be given a choice of providers from which to select.) When a patient is referred to another provider, or for emergency clinical care, the agency must:

  • make arrangements for the provision of pertinent individual information to the referral provider, obtaining required patient consent with appropriate safeguards to ensure confidentiality (i.e., adhering to HIPAA regulations);
  • advise the individual about his or her responsibility in complying with the referral; and
  • counsel the individual of the importance of the referral and follow-up method.