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Breast Cancer Screening

Advantage MD, EHP, Priority Partners / VBP, and USFHP. Female members 50-74 years of age.

  • Female members 50-74 years of age who had at least one bilateral mammograms to screen for breast cancer.
  • Dates acceptable from October 1 two years prior to the measurement year through December 31 of the measurement year.
  • Member Age is 52 years of age during measurement year.
  • Age 50 years of age reflects look back age of 50 or older on test date.

Best Practice and Measure Tips

  • This measure evaluates preventive screening only. Biopsies, breast ultrasounds or MRIs are not acceptable .
  • Results can be submitted for medical record review throughout year, but medical record review cannot be performed during HEDIS annual audit.
  • If documenting a mammogram in a member’s history, must specify bilateral 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.
  • The advanced illness exclusion can be identified from a telephone visit, e-visit or virtual check-in.

Measure Exclusions

Required Exclusions:

  • Palliative Care
  • Hospice
  • Fraility
  • Fraility and Advanced Illness
  • Living in Long Term Care

Optional Exclusions:
Bilateral mastectomy or two unilateral mastectomies 14 or more days apart. Any time in a member’s history through December 31 of the measurement year:

  • Any combination of codes that indicate a mastectomy on both the left and right sides on the same or different dates of service:
  • Bilateral mastectomy
  • History of bilateral mastectomy
  • Unilateral mastectomy with a bilateral modifier
  • Any combination of the following that indicate a mastectomy on both the left and right side:
    • Absence of the left or right breast
    • Unilateral mastectomy with a left-side modifier
    • Unilateral mastectomy with a right side modifier
    • Left unilateral mastectomy

Measure Codes

Mammography (Mammography Value Set)

  • CPT/CPT II 77055-57, 77061-63, 77065-67
  • HCPCS G0202, G0204, G0206

Exclusion Codes:

  • Mastectomy (History of Bilateral Mastectomy Value Set): ICD10CM
  • [Z90.13] Acquired absence of bilateral breasts and nipples
  • [Z90.12] Acquired absence of left breast and nipple
  • [Z90.11] Acquired absence of right breast and nipple
  • [Z90.13] Acquired absence of bilateral breasts and nipples.