outpatient primary care

 Colorectal cancer screening (ages 45-75)

Direct access colonoscopy: If amenable to procedure, has escort, and no indications for GI referral. Minor GI symptoms (chronic/stable and/or well-controlled symptoms), antiplatelet/anticoagulant use, and stable anemia (unless iron deficiency anemia of unknown etiology) do NOT require GI referral. Direct access is appropriate and faster.

[] Order 9211 [AMB REF TO COLONOSCOPY (SCREENING)]. Do not order prep or message anyone. Endoscopy nurse and colonoscopy navigator will review and handle prep and scheduling, or message you if needed. 

[] Diagnosis code Z12.11 or Z12.12

[] Document in your note any active GI symptoms or antiplatelet/anticoagulant use. The endoscopy nurse will review with GI physician supervision and contact you as needed. If patient has major GI symptoms that require specialist evaluation first or that may indicate upper endoscopy as well, then GI referral may be more appropriate. When in doubt, discuss with your preceptor and consider DAC (this is faster for the patient) given there will be chart review by the GI team prior to scheduling.

[] Include navigator contact info in checkout. Inform patient that he will reach out to them. Advise them to please give him 1-2 weeks to contact them before they reach out.

Refer to GI: If amenable to procedure, has escort, but has indication for GI evaluation prior to procedure. Indications include major GI symptoms including any new onset symptoms, conditions not well controlled on standard treatment, unintentional weight loss, iron deficiency anemia of unknown etiology, or any GI condition that may necessitate simultaneous diagnostic evaluation or additional procedures (e.g., colon biopsies, EGD).

[] Order 9010 [AMB REF TO GASTROENTEROLOGY]

[] Diagnosis code Z12.11 or Z12.12

[] Include scheduling info in checkout

Cologuard: If prefers noninvasive modality, can receive a kit in the mail and follow instructions. Patient must be average risk, no history of polyps and no family history of colorectal cancer, and willing to undergo colonoscopy if positive result (8-16% of tests). Read these instructions carefully to ensure patient receives the kit without issues and is prepared to complete it:

[] Ensure address and phone number are updated in Epic before signing the order. (This is transmitted directly to Exact Science to mail to patient.)

[] Order 81528.1 [STOOL FIT-DNA (COLOGUARD)]

[] Diagnosis code Z12.11 or Z12.12 (Important to ensure insurance coverage, if the wrong code the kit will not be delivered!)

[] Sign order before printing AVS (Printed instructions automatically attach, but you will not see them in the AVS preview)

[] Play patient instruction video during precepting or waiting on labs (can do on PC or rolling iPad) - helps with retention and kit completion! <https://www.cologuard.com/using-and-returning-your-cologuard-kit>

[] Tell patient that ExactSciences will contact them. 

[] Tell patient to expect follow-up from our dedicated Cologuard navigator within 1-2 business days to assist with delivery, instructions, and kit return.

FIT: If prefers noninvasive modality, cannot receive Cologuard kit or unable to follow Cologuard instructions. Patient must be average risk, no history of polyps and no family history of colorectal cancer, and willing to undergo colonoscopy if positive result (5-10% of tests).

[] Order 181331 [OCCULT BLOOD, FECAL BY IMMUNOASSAY (FIT)] -- normal order if in clinic, future order / lab collect if outside lab

[] Diagnosis code Z12.11 or Z12.12

[] If collecting in clinic, inform MA to collect. Do not obtain stool on digital rectal exam to avoid false positive due to digital trauma.

*Noninvasive tests must be followed up with colonoscopy if positive. Refer for direct access colonoscopy (order 9211) and message the navigator to expedite scheduling. Do not refer to GI first as this will delay workup.

Breast cancer screening (mammogram q2y in females aged 40-74)

[] Order IMGMG006 [SCREENING BILATERAL MAMMOGRAPHY AND DIAGNOSTIC AND/OR PROCEDURE, AS NEEDED]. This option allows follow-up studies to be ordered and scheduled by radiology.

[] Diagnosis code Z12.31

[] Include scheduling info in checkout

Cervical cancer screening (pap q3y in females with a cervix aged 21-30, q5y with HPV co-test in females aged 30-65)

[] Ensure patient has a cervix: no history of hysterectomy, and if hysterectomy that it did not spare the cervix

[] If normal or no prior screening history, refer to IMA Well Woman (order 9087 and check box for Well Woman to be scheduled by front desk)

[] If prior abnormal screen or active GYN problems, refer to GYN (order 9021 and include phone number for OB/GYN in checkout)

[] Diagnosis code Z12.4 or Z00.0

[] Include scheduling info in checkout

Lung cancer screening (ages 50-80 if >= 20 pack-years and EITHER current smoker OR quit within past 15 years)

[] Smoking history needs to be double-checked for patients who have ever smoked due to mass under-documentation of smoking history! Packs per day should reflect the AVERAGE number of packs per day over the patient's smoking career, not the current packs per day. 

[] CMS requirements: Shared decision-making must be conducted and documented, including discussing risks and benefits, and ensuring patient will undergo invasive procedures and treatment if indicated. Patient must be educated that smoking cessation is still the best way to prevent smoking-related morbidity and mortality even if undergoing screening.

[] Order G0297 [CT CHEST LOW DOSE LUNG CANCER SCREENING WITHOUT CONTRAST]

[] Diagnosis code V76.0

[] Include CT scheduling info in checkout.

Prostate cancer screening (PSA without DRE after shared-decision making in ages 55-69, consider age 40 if Black or +FMH):

USPSTF C recommendation means this should at a minimum be discussed with the patient, even if you decide not to screen. Interval is often ~q2y but can be individualized based on findings, sooner if elevated.

[] Discuss with preceptor prior to initiating screening.

[] Order 84153.02 [PSA, TOTAL]

[] Obtain bloodwork.