Form F 44729 PDF Details

Navigating the intricacies of healthcare documentation requires a keen understanding of specific forms, including the F-44729 form, pivotal within the Wisconsin Well Woman Program (WWWP). Crafted by the Department of Health Services, State of Wisconsin, this form is utilized for the cervical cancer diagnostic and follow-up reports, essential for both healthcare providers and members availing services through WWWP. It encompasses detailed sections ranging from billing provider information, member personal details, to diagnostic procedures undertaken for conditions like cervical dysplasia or invasive cervical cancer. The form allows for a systematic approach to document critical diagnostic procedures including colposcopy with or without biopsy, endocervical curettage, loop electrosurgical excision procedure (LEEP), cold knife cone, and endometrial biopsy. Results, whether negative, indicating abnormalities, or specifying the severity of dysplasia, are neatly categorized to facilitate further action plans. Recommendations for routine screening, short-term follow-up, or further diagnostic workups not covered by WWWP are also outlined, making the form a comprehensive tool for managing cervical health under the program. Its structured layout not only aids in the reimbursement process but also ensures that every facet of the diagnostic and follow-up care is meticulously reported and followed upon, emphasizing the state's commitment to women's health.

QuestionAnswer
Form NameForm F 44729
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesWNL, wisconsin well woman program follow up report drf, CCYY, Condyloma

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DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Public Health

s. 255.075, Wis. Stats.

F-44729 (10/08)

 

WISCONSIN WELL WOMAN PROGRAM

CERVICAL CANCER DIAGNOSTIC AND FOLLOW-UP REPORT (DRF)

INSTRUCTIONS: Before completing this form, refer to the Cervical Cancer Diagnostic and Follow-Up Report (DRF), F-44729A. For reimbursement, send claim plus this completed form to Wisconsin Well Woman Program (WWWP), P.O. Box 6645, Madison, WI 53716-0645.

SECTION I — BILLING PROVIDER INFORMATION

1. Provider ID

 

2. Name — Billing Provider

 

 

 

3. Taxonomy Code

 

 

4. Practice Location ZIP+4 Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II — MEMBER PERSONAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Last Name — Member

 

 

 

 

 

 

 

 

6. First Name — Member

7. Middle Initial — Member

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Previous Last Name — Member

 

 

 

 

 

9. Member Identification Number

10. Date of Birth (MM/DD/CCYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION III — CERVICAL DIAGNOSTIC PROCEDURES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COLPOSCOPY WITH BIOPSY / ENDOCERVICAL CURETTAGE

 

 

 

COLPOSCOPY WITHOUT BIOPSY

11.

Procedure Performed (Check One Box Only)

21. Date Performed (MM/DD/CCYY)

 

 

 

 

 

Colposcopy with Biopsy

Endocervical Curettage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

Date Performed (MM/DD/CCYY)

22. Name — Rendering Provider (Print)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

Name — Rendering Provider (Print)

23. RESULT (Check One Box Only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Negative (WNL)

 

 

 

 

 

 

 

 

14.

RESULT (Check One Box Only)

 

 

 

 

 

 

 

 

Other Abnormality

 

 

 

 

 

 

 

 

 

 

Negative (WNL)

 

 

 

 

 

 

 

 

 

 

 

Inflammation / Infection / HPV Changes

 

 

 

Other Non-malignant Abnormality (HPV, Condyloma)

 

 

Unsatisfactory

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CIN 1 / Mild Dysplasia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CIN 2 / Moderate Dysplasia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CIN 3 / Severe Dysplasia / CIS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Invasive Squamous Cell Carcinoma

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Adenocarcinoma

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOOP ELECTROSURGICAL EXCISION PROCEDURE (LEEP)

 

 

 

 

 

 

COLD KNIFE CONE

15.

Date Performed (MM/DD/CCYY)

24. Date Performed (MM/DD/CCYY)

 

 

 

16.

Name — Rendering Provider (Print)

25. Name — Rendering Provider (Print)

 

 

 

 

 

 

 

 

 

 

 

 

17.

RESULT (Check One Box Only)

 

 

 

 

 

 

26. RESULT (Check One Box Only)

 

 

 

 

 

Negative (WNL)

 

 

 

 

 

 

 

 

 

 

Negative (WNL)

 

 

 

 

 

 

 

 

 

 

Other Non-Malignant Abnormality (HPV, Condyloma)

 

Other Non-Malignant Abnormality (HPV, Condyloma)

 

 

CIN 1 / Mild Dysplasia

 

 

 

 

 

 

 

 

 

 

CIN 1 / Mild Dysplasia

 

 

 

 

 

 

 

 

CIN 2 / Moderate Dysplasia

 

 

 

 

 

 

 

 

CIN 2 / Moderate Dysplasia

 

 

 

 

 

 

 

CIN 3 / Severe Dysplasia / CIS

 

 

 

CIN 3 / Severe Dysplasia / CIS

 

 

 

 

 

 

Invasive Squamous Cell Carcinoma

 

 

Invasive Squamous Cell Carcinoma

 

 

 

Adenocarcinoma

 

 

 

 

 

 

 

 

 

 

 

Adenocarcinoma

 

 

 

 

 

 

 

 

 

 

 

ENDOMETRIAL BIOPSY

27. NOTES

 

 

 

 

 

 

 

 

18.Date Performed (MM/DD/CCYY)

19.Name — Rendering Provider (Print)

20.RESULT (Check One Box Only) Negative / Normal Endometrium Hyperplasia

Adenomatous Hyperplasia Atypical Adenomatous Hyperplasia Adenocarcinoma In-situ Adenocarcinoma

Shading indicates follow up required for WWWP.

28. RECOMMENDATION

Follow Routine Screening Schedule _______________________ Months

Short Term Follow up _________ Months

Further Diagnostic Work Up Treatment*

*Not covered by WWWP.

CONTINUED

CERVICAL CANCER DIAGNOSTIC AND FOLLOW UP REPORT (DRF)

 

Page 2 of 2

F-44729 (10/08)

 

 

 

 

 

 

 

SECTION III — CERVICAL DIAGNOSTIC PROCEDURES (CONTINUED)

 

 

29. STATUS OF FINAL DIAGNOSIS (Check One Box Only)

 

 

Complete*

Pending

Member Deceased

Lost to Follow up

Refused Work-up

*Must complete Element 30 (Final Diagnosis).

30.FINAL DIAGNOSIS (Required) Date (MM/DD/CCYY) ____________

Normal / Benign / Inflammation

HPV / Condyloma / Atypia

CIN I / Mild Dysplasia

 

CIN 2 / Moderate Dysplasia*

CIN 3 / Severe Dysplasia / CIS*

Invasive Cervical Cancer**

 

Adenocarcinoma of the cervix**

LSIL (Biopsy Diagnosis)

HSIL (Biopsy Diagnosis)*

 

*Complete Treatment Date and Treatment Status.

**Complete Treatment Date, Treatment Status, and Tumor Stage.

31. TUMOR STAGE (AJCC)

 

 

 

 

Stage I

Stage II

 

Stage III

Stage IV

32.TREATMENT STATUS — REQUIRED (Check One Box Only) Treatment Started

Refused by Member Lost to Follow up

Not Indicated / Not Needed Member Deceased

Alternative Treatment (e.g., homeopathic therapy, herbal medicine, etc.)

33.TREATMENT DATE (MM/DD/CCYY)

How to Edit Form F 44729 Online for Free

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It's an easy task to finish the document following this practical tutorial! This is what you must do:

1. To start with, when completing the WNL, start out with the section that has the next blanks:

WWWP conclusion process clarified (stage 1)

2. Now that this part is done, you'll want to include the necessary specifics in RESULT Check One Box Only cid, ENDOMETRIAL BIOPSY, Date Performed MMDDCCYY Name, RESULT Check One Box Only cid, and RESULT Check One Box Only cid so that you can progress further.

WWWP conclusion process clarified (part 2)

It's very easy to make an error when completing your RESULT Check One Box Only cid, so you'll want to look again prior to when you submit it.

3. Completing RESULT Check One Box Only cid, and Continued is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Filling in part 3 of WWWP

4. All set to begin working on this fourth portion! Here you have these cid Pending, cid Member Deceased, cid CIN Severe Dysplasia CIS, SECTION III CERVICAL DIAGNOSTIC, cid Stage II, cid Lost to Follow up, cid Refused Workup, cid CIN I Mild Dysplasia cid, Complete Treatment Date Treatment, cid Stage III, and cid Stage IV blanks to complete.

The best ways to fill out WWWP stage 4

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