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

Measurement Period: January 1 - December 31

Description: 
The percentage of episodes of mammograms documented in the form of a BI-RADS assessment within 14 days of the mammogram for persons 40–74 years of age.

Improvement Notation:
Increased score indicates improvement .

Data Collection:

• ECDS.  

Initial Population:

• Measure Item Count: Episode.
• Age: 40–74 years of age as of the episode date.
• Benefits: Medical.
• Continuous Enrollment: Date of episode through 14 days after episode.
• Allowable Gap: None. 

Definition:

BI-RADS Assessment: Clinically documented BI-RADS score. BI-RADS is a standardized classification system proposed by the American College of Radiology, used for imaging of mammography, ultrasound and MRI of the breast.

Intake Period: December 18 of the prior measurement period to December 17 of the measurement period. The intake period is used to capture the episode date.

Episode Date: The date of service for an eligible encounter during the intake period with a mammogram procedure.

Denominator: 
Mammogram.
Episodes of mammograms (Mammography Value Set) during the intake period.
Note: The measure is based on episodes; therefore, it is possible for the denominator to include multiple events for the same person. 

Numerator:
BI-RADS score.
Episodes of mammograms that receive a BI-RADS score on or within 14 days after the episode date (15 days total).

Best Practice and Measure Tips

• Evaluates the percentage of mammogram episodes documented with a BI-RADS assessment within 14 days for members aged 40 to 74.
• Educate members on importance of screening mammogram for early detection of breast cancer when there are usually no symptoms.
• Follow-up with Radiologist within 14 days of mammogram to get the Breast Imaging Reporting and Data Systems scoring (BI-RADS) and document in the member’s chart.
  • If the breast density is missing form mammogram report document, it in the member’s chart.
  • Provide clear communication about breast density, including compilation for cancer risk and screening follow-up.

NCQA Specs Clinical Recommendation Statement:

The National Comprehensive Cancer Network recommends breast cancer screening follow-up actions in alignment with the Breast Imaging Reporting and Data System (BI-RADS) scoring categories. The BI-RADS categorization offers specific recommendations for different findings:

• Category 0: Incomplete — Need Additional Imaging Evaluation and/or Prior Mammograms for Comparison, advises additional imaging.
• Category 1: Negative
• Category 2: Benign advises resuming routine screening.
• Category 3: Probably Benign, recommends diagnostic mammograms at 6 months, followed by repeat screenings every 6–12 months for 1–2 years, if appropriate.
• Category 4: Suspicious
• Category 5: Highly Suggestive of Malignancy, the recommendation is for tissue diagnosis using core needle biopsy (preferred) or needle localization excisional biopsy with specimen radiograph. When a needle biopsy (aspiration or core needle biopsy) is performed, obtaining concordance between the pathology report and the imaging finding is crucial.
• For Category 6: Known Biopsy-Proven Malignancy, the recommendation depends on the primary tumor, size of the invasive component, estimated disease volume, histological grade and other relevant characteristics.
• All recommendations are Category 2A recommendations. Based on lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

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.

Measure Codes

BI-RADS score

• RadLex Radiology Lexicon: RID36028, RID36029, RID36030, RID36031, RID36032, RID36033, RID36034, RID36035, RID36036, RID36041
• SNOMED CT US: 397138000, 397140005, 397141009, 397143007, 397144001, 397145000, 6111000179101, 6121000179106, 6131000179108, 6141000179100