5710 Cervical Cancer Screening
Revision 22-2; Effective April 1, 2022
The summary of cited guideline recommendations provided in this section reflects the ages of eligibility for HHSC 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 only a slight divergence was found among guidelines from different organizations, the recommendations were synthesized so that all 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 percent have not had a screening in the five years before 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 for Cervical Cancer Screening
- Cervical cancer screening should begin at age 21. Except for women who are infected with HIV or otherwise immunocompromised, screening should not be performed before 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 (for example, history of solid-organ transplant);
- History of in utero exposure to diethylstilbestrol; and
- Previous treatment for CIN 2, CIN 3 or cervical cancer.
- Liquid-based and 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, those considered high-risk HPV genotypes. Testing for low-risk genotypes, those without proven carcinogenic potential, should not be performed. References to HPV testing in the rest of this section are for high-risk HPV only.
- Screening guidelines should be applied to women who have received the HPV vaccine in the same way the guidelines are applied to women who have not received the vaccine.
Cervical Cancer Screening Frequency and Response to Abnormal Findings
- Routine annual cervical cancer screening is not needed for women of average risk in any age group.
- Women ages 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 ages 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 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 (ASCCP) and the Society of Gynecologic Oncology.
- For women ages 30 through 64, the following screenings are recommended:
- 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 used for screening, it should be done according to interim guidance provided by the ASCCP.
- 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 ASCCP.
Updated guidelines from the ASCCP recommend management of patients with abnormal cervical cancer screening results based on that individual’s risk of having or developing CIN 3 or greater. This means that different patients with the same current screening results may be managed differently, depending on cervical cancer screening results and treatment. Providers can determine recommended management for individual patients by consulting published tables or using an application or website designed for this purpose. Information about management of these types of cases is available under “Cervical Cancer Screening Resource for Providers” at the end of this section.
Discontinuation of Screening for Cervical Cancer
For women age 64 or younger, screening is stopped after a hysterectomy with removal of the cervix in individuals with no history of CIN 2 or greater.
References and Resources for Cervical Cancer Screening
American Society for Colposcopy and Cervical Pathology (2019). 2019 ASCCP Risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. Available at ASCCP Screening Guidelines.
Egemen, D., Cheung, L. C., Chen, X., Demarco, M., Perkins, R. B., Kinney, W., Poitras, N., Befano, B., Locke, A., Guido, R. S., Wiser, A. L., Gage, J. C., Katki, H. A., Wentzensen, N., Castle, P. E., Schiffman, M., & Lorey, T. S. (2020). Risk Estimates Supporting the 2019 ASCCP Risk-Based Management Consensus Guidelines. Journal of lower genital tract disease, 24(2), 132–143. https://doi.org/10.1097/LGT.0000000000000529.
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.
Cervical Cancer Screening Resource for Providers
American Society for Colposcopy and Cervical Pathology. ASCCP Risk-based management consensus guidelines Mobile App at https://www.asccp.org/mobile-app.
5720 Breast Cancer Screening
Revision 22-2; Effective April 1, 2022
The summary of guideline recommendations in this section pertains to individuals age 64 and younger and does not include recommendations for individuals outside this range.
Breast Cancer 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 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 ages 35 and older).
All individuals should be counseled on breast awareness and advised to be familiar with their breasts and to promptly report any changes (such as a mass, lump, thickening or nipple discharge).
Breast Cancer Screening Frequency
The following considerations* apply to women ages 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 BRCA1 or 2 mutations or other familial breast cancer syndrome) or a history of chest radiation at an early age.
- All individuals aged 50 through 64 should be offered screening mammography every other year.
- The decision for screening mammography in women aged 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 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 biologically related 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 may decrease call-back rates, although this practice might increase the total radiation dose.
- There is insufficient evidence to assess the balance of benefits and harms of breast ultrasonography, magnetic resonance imaging or other methods of adjunctive screening with women who have dense breasts identified on an otherwise negative screening mammogram.
More frequent or earlier screening mammography may be considered for women with increased or uncertain individual breast cancer risk and in other circumstances where the balance of potential benefits and harms of screening justifies such mammography.
*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 the following references and resources.
Breast Cancer Screening Follow-up and Referral for Treatment
Individuals with an abnormality found on screening or a specific breast complaint (including, but not limited to a mass, lump, thickening or nipple discharge) should be promptly evaluated, as indicated. Providers should have procedures in place to ensure appropriate individual education and counseling, referral for further evaluation (including other 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 to refer these individuals to an HHSC Breast and Cervical Cancer Services (BCCS) contractor. Information is available at Texas Health and Human Services Breast and Cervical Cancer Services and Texas Works Handbook, X-900, Medicaid Eligibility.
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 in X-900.
Breast Cancer Screening References and Resources
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.
Breast Cancer Screening 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.
Breast Cancer Screening Online Provider Resource
National Cancer Institute. Breast Cancer Risk Assessment Tool. Available at https://bcrisktool.cancer.gov.
5730 Sexually Transmitted Disease and Infection (STD and STI) Screening and Treatment
Revision 22-2; Effective April 1, 2022
The summary of cited guideline recommendations provided in this section reflect the ages of eligibility for the HHSC FPP (age 64 and younger) and do not include guideline recommendations for individuals outside this range.
Screening and treatment of STDs and 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 and STI screening recommendations (for more detailed information, go to the CDC screening links above).
- Contractors must provide HIV testing either on-site or by referral.
- If HIV testing is done, verbal or written consent must be documented in the medical record. If the patient refuses testing, the refusal must be documented. All individuals age 13 to 64 should be screened at least once for HIV according to a policy that provides HIV education and allows individuals to opt out of screening. With an opt-out screening, individuals are informed, before testing, that HIV testing will be done as part of the general consent for care and that they are free to decline testing. 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 and STIs should be tested for HIV at the same time.
- Contractors may provide negative HIV test results to individuals in person, by phone, or by the same method or manner as the results of other diagnostic or screening tests. The provision of negative test results by phone 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 who are 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.
Individuals 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 Program.
Chlamydia and Gonorrhea Testing
- Contractors must provide chlamydia and gonorrhea screening.
- Annual chlamydia and gonorrhea screening should be provided for all sexually active women under age 25. If a pelvic examination is not 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 vaginal swab obtained by the patient.
- Testing should also be done in women 25 years and 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 or STI;
- Symptoms or signs of cervicitis or an STD or STI;
- History of pelvic inflammatory disease;
- A positive test for an STD or STI in the previous12 months; and
- Sex work or drug use.
- Treated individuals should be retested 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 clinics focused on services for adolescents.
Herpes Simplex Virus (HSV) Screening
- 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 (that is, individuals who have 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 is appropriate in some circumstances:
- For people presenting for evaluation of an STD and/or STI (especially those who report multiple sexual partners) and persons with HIV infection;
- For men who have sex with men and whose HSV infection status is unknown, type-specific serologic testing may be appropriate to evaluate an undiagnosed genital tract infection;
- When infection 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 (that is, culture and PCR) are negative in a symptomatic patient; or
- For counseling patients about the risk of infection by a partner with known infection, especially during pregnancy.
Syphilis Screening (Men and Nonpregnant Women)
- Men and nonpregnant women who are at an 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 a higher risk for syphilis infection.
- Other factors associated with increased prevalence of syphilis infection are a history of incarceration or commercial sex work.
- According to 2018 CDC surveillance data, approximately 85.7 percent of syphilis cases occurred in men, with the highest rates in men ages 25 to 29.
- 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.
Other Screening and Pregnant Women
Screening for other infections and more frequent screening should be considered as appropriate based on the individual’s condition, risk factors and concerns.
- 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.
Patient-Delivered Partner Therapy (PDPT)
PDPT is the practice of providing therapy to the sexual partner or partners of a person being treated for chlamydia or gonorrhea without first developing a patient-clinician relationship with the partner or partners. Untreated partners can re-infect 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 for the partner or partners to reduce the risk of reinfections.
Providers may not receive reimbursement for providing partner treatment under this policy to persons who have not been patients.
American College of Obstetricians and Gynecologists. Committee Opinion No. 811: ACOG Clinical: The initial reproductive health visit. Available at https://www.acog.org/en/Clinical/Clinical%20Guidance/Committee%20Opinion/Articles/2020/10/The%20Initial%20Reproductive%20Health%20Visit.
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 Department of State Health Services. Expedited partner therapy website. Available at http://www.dshs.state.tx.us/hivstd/ept/default.shtm.
5740 Diabetes Mellitus Screening
Revision 22-2; Effective April 1, 2022
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 factors. An adult BMI calculator is available from the Centers for Disease Control and Prevention (CDC).
- Screen overweight or obese children or minors (age 19 or younger) who have 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 a 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 (for example, Alaskan Native American, African American, African Caribbean, Asian American, Hispanic and Latino, Native American, Pacific Islander and South Asian);
- Diabetes in a first-degree relative;
- Physical inactivity;
- Women who have had gestational diabetes or who have delivered a baby weighing greater than nine pounds;
- History of prediabetes: hemoglobin A1C greater than 5.7 percent (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.
Diabetes Diagnostic Criteria
The following test results, confirmed on repeat testing, meet the criteria for a diagnosis of diabetes (repeat testing for confirmation is not needed in the presence of unequivocal clinical hyperglycemia):
- Fasting plasma glucose (after no caloric intake for a minimum of eight 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 needed 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 postprandial 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.
Diabetes References and Resources
- 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. 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. Healthy Weight, Nutrition and Physical Activity: BMI Percentile Calculator for Child and Teen. Available at https://www.cdc.gov/healthyweight/bmi/calculator.html.
- Centers for Disease Control and Prevention. Defining childhood obesity (provides definition of overweight and obesity in children and minors 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.
5750 Hypertension Screening
Revision 22-2; Effective April 1, 2022
All individuals, including those with hypertension, should be advised to practice a healthful lifestyle as described in Section 5800, Healthful Lifestyle Intervention.
Classification of BP and Diagnosis of Hypertension
In the U.S., 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 individuals be screened at least annually for elevated BP.
The following table provides parameters and 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 and||Less than 80||Normal|
|120-129 and||Less than 80||Elevated|
|130-139 or||80-89||Stage 1 hypertension|
|140 or higher or||90 or higher||Stage 2 hypertension|
|180 or higher and/or||120 or higher||Hypertensive crisis|
Measurement of BP
To ensure correct measurement and monitoring of BP, follow these guidelines:
- For diagnosis of hypertension, BP readings should be based on the average of correct 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
To teach patients to correctly perform home BP monitoring, follow the steps below:
- 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 told to measure BP in the arm with the higher reading if there is a significant difference in the readings for both 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 part of the 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.
- BP measurements should be done daily, for one week before a clinic visit.
- Monitors with stored memory should be brought to all clinic appointments.
- Clinical decision making should be based on the average of readings taken on two or more occasions.
Nonpharmacologic Intervention for Elevated BP or Hypertension
All patients, regardless of BP category should receive instruction in a healthful lifestyle habits, with regular reinforcement of teaching.
- Weight loss should be recommended for adults who are overweight or obese.
- Persons with elevated BP or hypertension should adopt a healthy-heart diet (for example, the 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 standard drinks daily for men).
BP/Hypertension References and Resources
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.
5760 High Cholesterol Screening
Revision 22-2; Effective April 1, 2022
The summary of cited guideline recommendations provided in this section reflects the ages of eligibility for the HHSC FPP. It does 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 references and resources, and relevant textbooks outlined in the following section.
Rationale for Screening for High Cholesterol
Evidence shows that a healthful lifestyle (following a healthy-heart diet, maintaining a healthful weight, regular exercise and avoidance of tobacco products) reduces the risk of cardiovascular disease. In certain persons with specific risk factors, cholesterol-lowering medications (that is, statins) can further reduce the risk of an adverse health event. Measurement of blood cholesterol is a part of the individual risk assessment for some patients.
Who Should Be Screened for High Cholesterol?
- All men aged 35 and older;
- Men aged 20 through 35 years of age with increased risk for coronary heart disease; and
- Women aged 20 and older with increased risk for coronary heart disease (CHD).
No recommendation is made regarding routine screening in men aged 20 through 35 or in women aged 20 or older without increased risk of CHD.
High Cholesterol 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, such as:
- Personal history of CHD or noncoronary atherosclerosis;
- Family history of cardiovascular disease in men before age 50 and in women before age 60;
- Tobacco use;
- Hypertension; and
- Obesity (body mass index great than or equal to 30 kg/m2).
The best interval for screening is uncertain. Reasonable options include every five years, shorter intervals for people whose lipid levels are close to those calling for 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.
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.
Evaluation of Screening Results
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 for individuals:
- With clinical ASCVD, regardless of lipid profile results;
- With LDL cholesterol greater than or equal to 190 mg/dL;
- Age 40 or older with diabetes and LDL cholesterol greater than or equal to 70-189 mg/dL and no clinical ASCVD;
- Age 40 or older with diabetes and LDL cholesterol 70-189 mg/dL and no clinical ASCVD; or
- 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 percent.
Cholesterol References and Resources
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.
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/.
5770 Postpartum Depression Screening
Revision 22-2; Effective April 1, 2022
Prevalence and Risk Factors for Postpartum Depression
As much as 80 percent of new mothers experience a brief episode of the “baby blues,” which may last up to two weeks. Approximately 5 percent to 25 percent of new mothers 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:
- Symptoms of depression (especially in the third trimester) or anxiety during the pregnancy;
- Prior psychiatric illness or poor mental health, especially postpartum depression with a prior pregnancy;
- A history of physical, sexual or psychological abuse or domestic violence;
- Family history of depression, anxiety or bipolar disorder;
- Lack of social support;
- Low socio-economic status or educational level;
- Immigrant from another country;
- Medicaid insurance;
- Poor income or unemployment;
- Intention to return to work;
- Single parent status;
- Poor relationship with a partner or the father of the baby;
- Unintended pregnancy or a negative attitude toward the pregnancy;
- Traumatic childbirth experience;
- Stress related to child care issues;
- Medical illness, neonatal intensive care unit admission or prematurity in the infant;
- Difficulties with breastfeeding;
- A temperamentally difficult infant;
- A recent stressful life event or perceived stress;
- Smoking; or
- A history of bothersome premenstrual syndrome.
Common signs and symptoms of postpartum depression include the following (some or none of these symptoms may exist):
- Difficulty sleeping even when the baby is sleeping;
- Poor appetite;
- 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;
- Overwhelming fatigue;
- Poor concentration;
- Anger; or
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 conducted at a later visit.
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:
- Edinburgh Postnatal Depression Scale (EPDS); Cox, Holden and Sagovsky, 1987
- Patient Health Questionnaire-9 (PHQ-9); Spitzer, Kroenke and Williams, 1999
- Postpartum Depression Screening Scale (PDSS); Tatano Beck and Gable, 2002
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, discuss it with the woman and ask follow-up questions to evaluate her risk of postpartum depression.
Postpartum Referral for Treatment
Individuals in need of treatment for postpartum depression must 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, Local Mental Health Authorities or Local Behavioral Health Authorities, or call 211.
Coding for Postpartum Depression Services
The following Current Procedural Terminology (CPT) codes are covered under the HHSC FPP: 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 90791 and 90792.
References and Resources
American College of Obstetricians and Gynecologists Committee Opinion No. 757. ACOG Clinical: Screening for Perinatal Depression. Available at https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/11/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/.
Postpartum Depression: What is Postpartum Depression? Understanding, Support, Treatment, Resources. Available at https://www.postpartumdepression.org/
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.
5780 Suicide Risk Screening
Revision 22-2; Effective April 1, 2022
Individuals with a positive screen based on responses to questions related to suicide risk and individuals who express suicidal thoughts or ideation must be evaluated immediately for suicide risk. If the individual is felt to be acutely at risk of suicide, they must be referred for emergency evaluation and/or hospitalization, as indicated.