Breast Cancer Screening Tip Sheet

Incentives are paid to the linked primary care provider (PCP) on an annual basis, following the end of quarter four. For additional information, refer to the CBI Technical Specifications.

• Administrative members at the end of the measurement period.
• Dual coverage members.
• Members in hospice, receiving hospice services or palliative care or who died during the measurement year.
• Members who had a bilateral mastectomy or both left and right unilateral mastectomies at any time through the end of the measurement year or had gender-affirming chest surgery (CPT code 19318) with a diagnosis of gender dysphoria any time through the end of the measurement period.
• Members 66 years of age and older as of December 31 of the measurement year who meet both frailty and advanced illness criteria:
  • Frailty: At least two indications of frailty with different dates of service during the measurement year.
  • Advanced illness: One of the following during the measurement year or the year prior to the measurement year:
    • Encounter with an advanced illness diagnosis on at least two different dates of service.
    • Dispensed dementia medication.

  Note: Laboratory claims with POS 81 are not included to identify eligible members with diagnostic codes for frailty or advanced illness or encounters for palliative care.

  Note: Medi-Cal pharmacy benefits are provided through Medi-Cal Rx. You can access their Contact Drugs List, Medi-Cal Rx portal, subscribe to Medi-Cal Rx news updates or locate a Medi-Cal Rx pharmacy on the DHCS Medi-Cal Rx homepage.

Members meet eligibility if they had one or more mammograms any time on or between October 1 two years prior to the measurement year and December 31 of the measurement year.

Acceptable codes include:

Note: All types and methods of mammograms (screening, diagnostic, film or digital breast tomosynthesis) qualify for compliance. Do not count MRIs, ultrasounds or biopsies.

To indicate a member’s history of bilateral mastectomy, report ICD-10 code Z90.13 on any claim at least once during the measurement period or submit via the Data Submission Tool (DST) on the Provider Portal. This code should not be listed as a primary diagnosis.

To report a gender-affirming chest surgery, report CPT code 19318 with an ICD-10 diagnosis of gender dysphoria any time through the end of the measurement period.

Note: CPT code and one ICD-10 code required.

DST-specific submissions for sex assigned at birth

Members can be included in the measure if the sex assigned at birth (LOINC code 76689-9) of female (LA-3-6) is submitted any time during the member’s history. These codes can be submitted through the Data Submission Tool on the Provider Portal.

For a full list of inclusive and exclusive code sets, please refer to the CBI Technical Specifications

Data for this measure is collected using claims, DHCS fee-for-service encounter claims and provider data submissions via the Data Submission Tool (DST) on the Provider Portal. To find gaps in data:

• Run a report from your electronic health record (EHR) system; or
• Manually compile patient data. For example, download the monthly Breast Cancer Screening Quality report or your Care-Based Incentives Measure Details report on the Provider Portal and compare it to your EHR/paper records.

This measure allows providers to submit breast cancer screening and bilateral mastectomy information from the clinic EHR system or paper records to the Alliance by the DST contractual deadline. To submit, upload data files to the DST on the Provider Portal. To be accepted, data must be submitted as a CSV file. Step-by-step instructions are available in the Data Submission Tool Guide on the Provider Portal.

• Incorporate standing orders for breast cancer screenings into your daily practice. For an example of mammography standing orders, refer to the UCSF Center for Excellence in Primary Care – Standing Orders.
• Educate female members about the importance of early detection and encourage screenings.
• Make yearly mammograms a standard part of discussion during every visit.
• Designate a care team member to use the Alliance Provider Portal reports to do chart reviews and call members who are due for this important screening.
• Create a recall list for patients that no showed or canceled to reschedule them for their screenings.
• Note that some imaging/mammography centers require a referral. Send referrals to imaging centers at the end of the clinic day, instead of batching them, to reduce the number of lost referrals. The Alliance does not require prior authorization.
• Help members schedule appointments with imaging centers while they are in the office or provide members with a list of nearby contracted imaging/mammography centers.
• Refer to the Patient-Friendly Summary of the American College of Radiology Appropriateness Criteria: Transgender Breast Cancer Screening and The Confusing World of Breast Cancer Screening for Transgender People for breast cancer screening recommendations for transgender females and non-binary people who are assigned sex at birth as male:
  • If less than five years of hormone use and average risk, no testing.
  • If less than five years of hormone use, 25 to 30 years of age or older, and higher-than-average risk, annual digital breast tomosynthesis (DBT, also called a 3D mammogram) or mammogram may be appropriate.
  • If five or more years of hormone use, 25 to 30 years of age or older, and higher-than-average risk, annual DBT or mammogram is usually appropriate.
  • If five or more years of hormone use, 40 years of age or older, and average risk, annual DBT or mammogram may be appropriate.

• Alliance Cultural and Linguistic Services are available to network providers.
  • Language Assistance Services – Request materials at 800-700-3874, ext. 5504.
  • Telephonic Interpreter Service – Directly access a telephonic interpreter 24 hours a day, 7 days a week.
  • Interpreter Services – Can be requested for the appointment with the member.
  • Virtual Remote Interpreter (VRI) Service – When an in-person interpreter might not be available or easy to access.
  • For information about the Cultural and Linguistic Services Program, call the Alliance Health Education Line at 800-700-3874, ext. 5580 or email us at [email protected].
• Alliance Transportation Services for patients with transportation challenges.
  • For non-emergency medical transportation (NEMT) services, call 800-700-3874, ext. 5640 (TTY: Dial 711).
  • For non-medical transportation (NMT) services, call 800-700-3874, ext. 5577 (TTY: Dial 711).
• Breast Cancer: Screening - U.S. Preventive Services Task Force Final Recommendation.
• Breast Cancer Screening Evidence-Based Programs Listing - National Cancer Institute.
• Cancer Screening: Multicomponent Interventions—Breast Cancer – Community Preventive Services Task Force.
• Centers for Disease Control and Prevention patient resource information:
  • Screening for Breast Cancer
  • Four Women Tell Their Stories
  • About Dense Breasts
• Health and Economic Benefits of Breast Cancer Interventions – Centers for Disease Control and Prevention.