Breast Cancer Screening Tip Sheet

Incentives will be paid to the linked primary care provider (PCP) on an annual basis, following the end of Quarter 4. For additional information, refer to the CBI Technical Specifications.

Members in hospice or receiving hospice services or palliative care during the measurement year.

Members who died any time during the measurement year (CBI 2024 only).

Members 66 years of age and older as of December 31 of the measurement year with frailty and advanced illness:

• At least two indications of frailty with different dates of service during the measurement year (one encounter for CBI 2023 only).
• At least one of the following during the measurement year or year prior to the measurement period:
  • At least two outpatient, observation, emergency department (ED) visits or non-acute inpatient encounter on a different date of service (DOS), with an advanced illness diagnosis. Visit types must be the same for the two visits.
  • At least one acute inpatient encounter with an advanced illness diagnosis.
  • Dispensed dementia medication.

Members who had a bilateral mastectomy or two unilateral mastectomies at any time prior to December 31 of the measurement year will be excluded.

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 on the Provider Portal. This code should NOT be listed as a primary diagnosis.

Data for this measure will be collected using claims, DHCS Fee-for-Service encounter claims, and the 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 (Example: Download monthly breast cancer screening quality report or your Care-Based Incentives Measure Details report on the Provider Portal and compare to your EHR/paper charts).

This measure allows providers to submit bilateral mastectomy information from the clinic EHR system or paper records by the DST contractual deadline. To submit, you may upload data files to the DST on the Provider Portal. 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.
• 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’s Provider Portal reports to do chart review and call members who are due for this important screening.
• Create a recall list for patients that no showed or canceled to attempt at rescheduling them for their screenings.
• Note that some imaging/mammography centers require a referral. Send referrals to imaging centers at the end of clinic day instead of batching to the reduce number of lost referrals. The Alliance does not require prior authorization.
• Assist members with scheduling appointments with imaging centers while they are in the office or provide members with a list of nearby contracted imaging/mammography centers.
• Alliance interpreting services are available to network providers:
  • Telephonic interpreting services are available to assist in scheduling members.
  • Face-to-face female interpreters can be requested to assist at the breast cancer screening appointment.
• Refer patients that have transportation challenges to the Alliance’s Transportation Coordinator at 800-700-3874 ext. 5577. This service is not covered for non-medical locations or appointments that are not medically necessary.

• NIH Breast Cancer Screening Evidence-Based Programs Listings
• CDC Breast Cancer Screening Change Package
• CDC's Power of Prevention: Health and Economic Benefits of Breast Cancer Interventions
• CPSTF Cancer Screening: Multicomponent Interventions Breast Cancer
• ASTHO Breast Cancer Disparities Online Toolkit
• CDC patient resource information:
  • What Is Breast Cancer Screening?
  • The Right to Know Campaign Breast Cancer Screening
  • If Your Mammography report says you have dense breasts, what does that mean?