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Johns Hopkins Health Plans

FMA-E Follow-Up After Abnormal Mammogram Assessment

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

Measurement Period: January 1 - December 31

Description: 
The percentage of episodes for persons 40-74 years of age with inconclusive or high-risk BI-RADS assessments that received appropriate follow-up within 90 days of the assessment.

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 90 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: October 3 of the year prior to the measurement period to October 2 of the measurement period. The intake period is used to capture the episode date.

Episode Date: The dates of service during the intake period when a high-risk or inconclusive BI-RADS score was documented.

Denominator:
Episodes of high-risk or inconclusive BI-RADS assessment.
Episodes with a high-risk or inconclusive BI-RADS assessment 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:
Appropriate follow-up for high-risk or inconclusive BI-RADS assessment.

High-risk and inconclusive BI-RADS assessment during the Intake Period that received appropriate follow-up. Appropriate follow-up is defined as either of the following:

  • A high-risk BI-RADS assessment result (Category 4: Suspicious – Category 5: Highly Suggestive of Malignancy), that received a breast biopsy on or within 90 days after the episode date (91 days total).
  • An inconclusive BI-RADS assessment (BI-RADS 0: Incomplete — Need Additional Imaging Evaluation and/or Prior Mammograms for Comparison), that received a mammogram or ultrasound on or within 90 days after the episode date (91 days total).

Best Practice and Measure Tips

  • Assesses the percentage of episodes with inconclusive or high-risk BI-RADS assessments that receive appropriate follow-up within 90 days for members aged 40–74.
  • This measure focus on improving screening and follow-up care for breast cancer.
  • To ensure member receive the best care, request prior mammograms reports to be use for comparison prior the member’s scheduled mammogram appointment to prevent the need for additional information or incomplete assessments.
  • Document breast density if missing from the mammogram report.
  • Educate member about dense breasts and how it can affect mammogram.
  • Patient with higher risk factors, ensure you coordinate care with Radiologist and Oncologist.
  • Provide timely communication of results and clear instruction for follow up actions.
  • Provide Educational materials on abnormal mammogram results.

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

Breast Biopsy

  • CPT: 19081, 19083, 19085, 19100, 19101 
  • SNOMED CT US Edition: 10940003, 28768007, 42125001, 44578009, 116219004, 116220005, 116334007, 172086006, 237372000, 237375003, 237376002, 237377006, 237378001, 237379009, 265253005, 274331003, 287553003, 303689004, 307298009, 387736007, 432109009, 432157003, 432337008, 432550005, 433008009, 433685008, 433805008, 442963006, 445171002, 445437001, 448336005, 448689003, 709628007, 711508007, 723990008, 725936002, 736615002, 770568001, 770569009, 770570005, 771086002, 771625002, 785800009, 786883001, 866232001, 1179705005, 1179707002, 1179708007, 1220570007, 1220571006, 1220572004, 1264555004, 1264556003, 1268323005, 1268996004, 1332066007, 1332067003, 1333891002, 1333892009, 1333893004, 1333894005, 1333895006, 1333896007, 1333897003, 1333898008, 1333899000, 1333900005, 1333901009, 1333902002, 1333903007, 1333904001, 1333905000, 1333906004, 1334078005, 1334079002, 1334080004, 1356791009, 2131000087106, 2141000087100, 2841000087108, 4541000087104, 4551000087101, 5181000087103, 12131000087109, 305011000000108, 305051000000107, 305071000000103, 306371000000109, 306381000000106, 306641000000107, 306651000000105, 306671000000101, 307971000000105, 307981000000107, 308041000000102, 872731000000104 

Breast Ultrasound

  • CPT: 76641, 76642
  • LOINC: 105420-4, 105421-2, 24599-3, 24601-7, 26215-4, 26216-2, 26288-1, 26290-7, 42132-1

Mammography

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