Product Lines:
Advantage MD, EHP, Priority Partners and USFHP.

Measurement Period: January 1 - December 31

Description:
The percentage of persons 40–74 years of age who were recommended for routine breast cancer screening and had a mammogram to screen for breast cancer.

Note: A unilateral or bilateral mammogram is acceptable; however, a bilateral mammogram is preferred for compliance. 

Stratifications:

Age as of the last day of the measurement period.

• 42-51 years
• 52-74 years

Report stratification by race and ethnicity.
Report stratification by SES only for Advantage MD (Medicare product line).

Measure Reporting:
CMS Start Rating Measure.
Population Health Incentive Program (PHIP).
HealthChoice Performance Measure reporting for Priority Partners. 

Improvement Notation:
Increased score indicates improvement.

Data Collection:

• ECDS

Initial Population:

• Measure Item Count: Person.
• Age: 42–74 years of age as of the last day of the measurement period.
• Gender/sex criteria (persons recommended for routine breast cancer screening):
  
  • Administrative Gender of Female (AdministrativeGender code female) any time in the person’s history.
  • Sex assigned at birth (LOINC code 76689-9) of Female (Female Value Set) any time in the person’s history.
  • Sex Parameter for Clinical Use of Female (SexParameterForClinicalUse code female-typical) during the measurement period.
• Benefits: Medical.
• Continuous Enrollment: October 1 two years prior to the measurement period through the last day of the measurement period.
• Allowable Gap:
  
  • Measurement period: No more than one gap of ≤45 days. No gaps on the last day of the measurement period.
  • Year prior to the measurement period: No more than one gap of ≤45 days. 
  • October 1 two years prior to the measurement period through December 31 two years prior to the measurement period: None. 

Denominator:
The initial population minus denominator exclusions.

Numerator:
At least one mammogram.
One or more mammograms (Mammography Value Set) any time on or between October 1 two years prior to the measurement period and the last day of the measurement period.

Best Practice and Measure Tips

• This measure evaluates preventive screening only.
• The advanced illness exclusion can be identified from a telephone visit, e-visit or virtual check-in.

Acceptable:

• Bilateral or Unilateral mammogram performed during the measurement period.
  • Results can be submitted for medical record review throughout the year, but medical record review cannot be performed during HEDIS annual audit.
• Documentation “mammogram completed” and date.
  • If documenting a mammogram in a member’s history specify mammogram and date of service. If unilateral mammogram, must include documentation of unilateral mastectomy. If the date is unknown, year only is acceptable. The result is not required.
  • Submit the appropriate ICD-10 diagnosis code that reflects a member’s history of bilateral mastectomy, Z90.13.
  • Attempt to obtain reports for member reported screening. Notate place of service if unable to obtain report.
  • Educate members on importance of screening mammogram for early detection of breast cancer when there are usually no symptoms.
• Types of mammograms: Screening, Diagnostic, Film, Digital, or Digital Breast Tomosynthesis (3-D Mammogram).

Note: CAD (Computer-Aided Detection) is only designed to help improve Results for Mammography, MRI, CT’s and X-rays, but this term alone does not make the member compliant. The appropriate screening type needs to be completed.

Not Acceptable:

• Biopsies, Breast Ultrasounds or MRI’s.

Measure Exclusions

Denominator Exclusions:

• Persons in hospice or using hospice services any time during the measurement period.
• Persons who died any time during the measurement period.
• Persons receiving palliative care or who had an encounter for palliative care any time during the measurement period.
• Medicare enrollees, 66 years of age and older by the last day of the measurement period, in an institutional SNP (I-SNP) or living long-term in an institution (LTI).
• Persons 66 years of age or older by the last day of the measurement period, with both frailty and advanced illness.
• Documentation of bilateral mastectomy anytime in member’s history through December 31 of the measurement year.
  • Documentation must indicate a mastectomy on both the left and right side on the same or different dates of service.
    • Any of the following meet criteria for bilateral mastectomy:
      • A bilateral mastectomy.
      • A unilateral mastectomy on both the left and right side on the same or different dates of service.
      • Two unilateral mastectomies, which do not specify left and right, must be performed 14 days or more apart.
• Members who had gender-affirming chest surgery with a diagnosis of gender dysphoria any time during the member’s history through the end of the measurement period.

Exclusion Codes:

Bilateral mastectomy: 

• ICD10PCS: 0HTV0ZZ
• SNOMED CT US Edition: 14693006, 14714006, 17086001, 22418005, 27865001, 52314009, 60633004, 76468001, 456903003, 726636007, 836436008, 870629001, 1268980002, 1269061009, 1279986002

Mastectomy (History of Bilateral Mastectomy Value Set):

• ICD-10-CM:  [Z90.13] Acquired absence of bilateral breasts and nipples
• SNOMED CT US Edition: 428529004, 136071000119101

Unilateral mastectomy

• CPT: 19180, 19200, 19220, 19240, 19303, 19304, 19305, 19306, 19307
• Modifiers: 50, LT, RT

Absence of Left Breast:

• ICD-10-CM: [Z90.12] Acquired absence of left breast and nipple
• SNOMED CT US Edition: 429009003, 137671000119105

• ICD-10-CM: [Z90.11] Acquired absence of right breast and nipple
• SNOMED CT US Edition: 429242008, 137681000119108

Unilateral Mastectomy Left

• ICD-10-PCS: [0HTT0ZZ] Resection of Right Breast, Open Approach
• SNOMED CT US Edition: 428571003, 726429001, 726435001, 726437009, 741009001, 741018004, 836437004

Unilateral Mastectomy Right

• ICD-10-PCS: [0HTU0ZZ] Resection of Left Breast, Open Approach
• SNOMED CT US Edition: 429400009, 726430006, 726434002, 726436000, 741010006, 741019007, 836435007

Clinical Unilateral Mastectomy

• SNOMED CT US Edition: 5835009, 5884001, 24268003, 64837009, 66398006, 70183006, 116221009, 150298000, 150301001, 150302008, 150303003, 150304009, 150305005, 150306006, 150307002, 172039007, 172040009, 172041008, 172042001, 172043006, 172046003, 172047007, 172050005, 237367009, 237368004, 265248000, 274957008, 287652002, 287653007, 287654001, 302341009, 318190001, 359728003, 359731002, 359734005, 359738008, 359740003, 384723003, 395701007, 395702000, 406505007, 428564008, 446109005, 446420001, 447135002, 447421006, 1208601007
• Left mastectomy SNOMED CT US Edition: 361716006
• Right mastectomy SNOMED CT US Edition: 36171005

Gender-affirming chest surgery with a diagnosis of gender dysphoria

• CPT: 19318
• ICD-10-CM: F64.1, F64.2, F64.8, F64.9, Z87.890

Measure Codes

Mammography

• CPT: 77061, 77062, 77063, 77065, 77066, 77067
• LOINC: 86463-7, 72139-9, 91519-9, 91522-3, 72142-3, 72138-1, 91518-1, 91521-5, 72141-5, 72137-3, 91517-3, 91520-7, 72140-7, 86462-9, 103892-6, 38090-7, 26346-7, 48475-8, 26349-1, 46351-3, 26287-3, 37554-3, 37543-6, 37006-4, 37016-3, 26175-0, 48492-3, 46335-6, 37552-7, 37029-6, 37038-7, 36626-0, 38071-7, 42415-0, 37052-8, 36642-7, 38091-5, 26347-5, 69150-1, 26350-9, 26289-9, 37005-6, 38854-6, 37017-1, 26176-8, 103885-0, 46336-4, 37553-5, 37030-4, 38855-3, 36627-8, 38072-5, 42416-8, 37053-6, 37768-9, 26348-3, 69259-0, 26351-7, 26291-5, 37773-9, 37769-7, 37775-4, 26177-6, 103886-8, 46337-2, 38807-4, 37770-5, 37771-3, 37774-7, 38820-7, 37772-1, 46350-5, 46356-2, 46338-0, 46339-8, 46380-2, 36319-2, 36962-9, 24605-8, 103894-2, 24604-1, 37539-4, 24610-8, 37542-8, 24606-6, 103893-4, 37551-9, 37028-8, 37037-9, 36625-2, 38070-9, 69251-7