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

Eligible Population:
Women 52-74 years of age as of December 31 of the measurement year. This includes Population Health Incentive Program (PHIP) and HealthChoice Performance Measure reporting for Priority Partners.

Definition:
Women 50-74 years of age who had a mammogram to screen for breast cancer on or between October 1 two (2) years prior to the measurement year and December 31 of the measurement year. (Age range notes 50 years of age: this reflects look back age of 50 or older on test date.)

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

Include members recommended for routine breast cancer screening with any of the following criteria:

• Administrative Gender of Female (AdministrativeGender code female) at any time in the member’s history.
• Sex Assigned at Birth (LOINC code 76689-9) of Female (LOINC code LA3-6) at any time in the member’s history.
• Sex Parameter for Clinical Use of Female (SexParameterForClinicalUse code female-typical) during the measurement period.

Continuous Enrollment:

• October 1 two years prior to the measurement year through December 31 of the measurement year.

Best Practice and Measure Tips

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

 

Measure Exclusions

Required Exclusions:

• Must occur during the measurement year:
  • Hospice or using hospice services
  • Palliative care
  • Deceased
  • Medicare members 66 years of age and older by the end of the measurement period who meet either of the following:
    • Enrolled in an Institutional SNP (I-SNP).
    • Living in Long Term Care.
  • 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
• Mastectomy (History of Bilateral Mastectomy Value Set): 
  • ICD-10-CM:  [Z90.13] Acquired absence of bilateral breasts and nipples
• Unilateral mastectomy
  • CPT: 19180, 19200, 19220, 19240, 19303, 19304, 19305, 19306, 19307
  • Modifiers: 50, LT, RT
• ICD-10-CM: 
  • [Z90.12] Acquired absence of left breast and nipple
  • [Z90.11] Acquired absence of right breast and nipple
• ICD-10-PCS: 
  • [0HTU0ZZ] Resection of Left Breast, Open Approach
  • [0HTT0ZZ] Resection of Right Breast, Open Approach
• 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: 77062, 77061, 77066, 77065, 77063, 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