pqri measure coding and reporting principles - Indiana Academy of ...

RISK ASSESSMENT FORM
A screening pelvic examination (including a clinical breast examination) and/or screening pap smear is a
covered Medicare service once every two years, unless a patient is considered high-risk for cervical or
vaginal cancer. Listed below are the criteria considered to be high-risk. If you meet any of the following,
and wish to share this information with us, the screening pelvic and/or screening pap may be paid
annually.
_____ Childbearing age and have had an examination indicating the presence of cervical or
vaginal cancer or other abnormality during any of the preceding three years
_____ Early onset of sexual activity (under 16 years of age)
_____ Multiple sexual partners (five or more in a lifetime)
_____ History of sexually transmitted disease (including the human immunodeficiency virus
[HIV])
_____ Any of the last three pap smears were positive
_____ No pap smear within the past seven years
_____ Prenatal exposure to diethylstilbestrol
OR
_____ None of the above (payment may be made by Medicare once every two years)
__________________________________________
Signature
________________________
Date
*All CPT Codes, Descriptions, and Two-Digit Modifiers
Only Are Copyright 2006 American Medical Association. IAFP Annual Meeting 2007
Copyright 2007 Newby Consulting, Inc.
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