Measure Code: BCS Lab Data: N
Rule Description: The percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.
Applicable Provider Specialty: Family Practice, Geriatric Medicine, Internal Medicine, Mixed Specialties Clinic, Obstetrics-Gynecology
General Criteria Summary
1. Measurement period: 1 year prior to measurement period end date
2. Continuous enrollment: 27 months
3. Anchor date: measurement period end date (ie. December 31 of calendar year)
4. Gaps in enrollment: One 45-day gap allowed in each year of continuous enrollment
5. Medical coverage: Yes
6. Drug coverage: No
7. Attribution time frame: 27 months
8. Exclusions apply: Yes, when numerator is negative
9. Age range: 50-74 years
Summary of changes for 2014
1. NCQA replaced all coding table references with value set references.
2. NCQA changed the age range from 40-69 years of age to 50-74 years of age.
3. NCQA changed the measurement period from the measurement year and the year prior, to October 1 two years prior to the measurement year through December 31 of the measurement year. This effectively adds 3months to the measurement period (from 24 to 27 months) and impacts continuous medical benefit enrollment (increasing to 27 months) and the numerator time frame (increasing to 27 months).
Denominator Description: All women aged 52-74 years at the end of the measurement year
Inclusion Criteria: Women aged 52-74 as of the end of the measurement year
Unilateral Mastectomy Value Set
Code Code Type Description
19180 CPT Mastectomy, simple, complete
19200 CPT Mastectomy, radical, including pectoral muscles, axillary lymph nodes
19220 CPT Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes
19240 CPT Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding
19303 CPT Mastectomy, simple, complete
19304 CPT Mastectomy, subcutaneous
19305 CPT Mastectomy, radical, including pectoral muscles, axillary lymph nodes
19306 CPT Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes
19307 CPT Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding
85.41 ICD-9-CM Procedure Unilateral simple mastectomy
85.43 ICD-9-CM Procedure Unilateral extended simple mastectomy
85.45 ICD-9-CM Procedure Unilateral radical mastectomy
85.47 ICD-9-CM Procedure Unilateral extended radical mastectomy
Bilateral Mastectomy Value Set
CPT Code Type Description
85.42 ICD-9-CM Procedure Bilateral simple mastectomy
85.44 ICD-9-CM Procedure Bilateral extended simple mastectomy
85.46 ICD-9-CM Procedure Bilateral radical mastectomy
85.48 ICD-9-CM Procedure Bilateral extended radical mastectomy
CODING/BILLING INFORMATION Prophylactic Mastectomy
The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered.
CPT CODES
19301 Partial mastectomy (i.e., lumpectomy)
19302 Partial mastectomy with lymphadenectomy
19303 Simple complete mastectomy
19304 Subcutaneous mastectomy
19305 Radical mastectomy including pectoral muscles, axillary lymph nodes
19306 Radical mastectomy including pectoral muscles, axillary and internal mammary lymph nodes (urban type)
19307 Modified radical mastectomy with or without pectoralis minor muscles, axillary lymph nodes but excluding pectoralis major muscle
ICD-9 CODE
V50.41 Prophylactic breast removal
ICD-10-CM CODE; EFFECTIVE 10/01/2015
Z40.01 Encounter for prophylactic removal of breast
Prior Authorization
Services that require prior authorization must be requested using the CSHCN Services Program Authorization and Prior Authorization Request form. If any information on the prior authorization changes after services have been approved, providers must update the prior authorization before they submit claims
Expanded Coverage of PET Scans for Breast Cancer Effective for Dates of Service on or After October 1, 2002
Effective for dates of service on or after October 1, 2002, Medicare will cover FDG PET as an adjunct to other imaging modalities for staging and restaging for locoregional, recurrence or metastasis of breast cancer. Monitoring treatment of a locally advanced breast cancer tumor and metastatic breast cancer when a change in therapy is contemplated is also covered as an adjunct to other imaging modalities. The baseline PET study for monitoring should be done under the code for staging or restaging.
Medicare continues to have a national non-coverage determination for initial diagnosis of breast cancer and initial staging of axillary lymph nodes. Medicare coverage now includes PET as an adjunct to standard imaging modalities for staging patients with distant metastasis or restaging patients with locoregional recurrence or metastasis of breast cancer; as an adjunct to standard imaging modalities for monitoring for women with locally advanced and metastatic breast cancer when a change in therapy is contemplated.
Procedure Codes for PET Scans Performed on or After October 1, 2002 for Breast Cancer
Contractors shall advise providers to use the appropriate Procedure code from section 60.3.1 for covered breast cancer indications for services performed on or after January 28, 2005.
NOTE: The NCD Manual contains a description of coverage. FDG Positron Emission Tomography is a minimally invasive diagnostic procedure using positron camera [tomograph] to measure the decay of radioisotopes such as FDG. The CMS determined that the benefit category for the requested indications fell under §1861(s)(3) of the Act diagnostic service.
