Measure Name: Cancer Screen Owner: NCQA (BCS) Measure Code: BCS Lab Data: N Rule Description: The percentage of women 40-69 years of age who had a mammogram to screen for . General Criteria Summary 1. Continuous enrollment: 2 years 2. Anchor date: 31st December of the measurement year 3. Gaps in enrollment: One 45-day gap allowed in each year of continuous enrollment 4. Medical coverage: Yes 5. Drug coverage: No 6. Attribution time frame: 2 years 7. Exclusions apply: Yes, when numerator is negative 8. Age range: 40-69 years

Summary of changes for 2013 1. Added CPT modifier codes RT and LT to Table BCS-B and revised the optional exclusion for bilateral to include instances where a mastectomy is performed on the right side and the left side of the body on the same date of service.

------Denominator Description: All women aged 42-69 years at the end of the measurement year Inclusion Criteria: Women aged 42-69 as of the end of the measurement year Eligibility Criteria Condition # Detailed Criteria Timeframe Description Evnt Gender Code Gender Code = F AND Age is 42-69 Age in Years = 42-69 As of the end of the measurement year AND Has medical coverage Coverage Indicator Medical = Y During measurement year and the year prior to the measurement year

3/7/2014 Page 1 Exclusion Criteria: Women with a previous bilateral mastectomy or two unilateral

Condition # Evnt Detailed Criteria Timeframe Description Previous bilateral 1 CPT Procedure codes for mastectomy Anytime prior to or during the measurement year mastectomy Table BCS-B: Codes to Identify Exclusions And (Procedure Modifier Code 1 = 50 (Bilateral procedure) Or (Procedure Modifier Code 1 = LT (left- side procedure) And Procedure Modifier Code 1 = RT (right- side procedure)))

Or ICD-9 procedure codes for bilateral mastectomy Table BCS-B: Codes to Identify Exclusions OR Two previous 2 (with diff CPT Procedure codes for mastectomy Anytime prior to or during the measurement year unilateral dates of Table BCS-B: Codes to Identify mastectomies with service) Exclusions different dates of Or service ICD-9 procedure codes for unilateral mastectomy Table BCS-B: Codes to Identify Exclusions

Exclusion Note: The exclusions are applied according to the general NCQA rule of considering exclusions only if the numerator is negative

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3/7/2014 Page 2 Numerator Description: For each woman who meets the denominator criteria, those who received a mammogram during the measurement year or the year prior to the measurement year Inclusion Criteria: Women who had at least one mammogram during the measurement year or the year prior to the measurement year

Condition # Detailed Criteria Timeframe Description Evnt At least one 1 CPT Procedure Code for Mammogram During the measurement year or the year prior to the measurement year mammogram Table BCS-A: Codes to Identify Breast Cancer performed Screening Or HCPCS Procedure Code for Mammogram Table BCS-A: Codes to Identify Or ICD9 Procedure Code for Mammogram Table BCS-A: Codes to Identify Breast Cancer Screening Or Revenue Code UB Table BCS-A: Codes to Identify Breast Cancer Screening

Notes: 1. Because HCSC has historical data, the search for exclusion criteria extend to 10 years of data. 2. In 2012, ICD-9 Diagnosis codes V76.11 and V76.12 were deleted from Table BCS-A. 3. In 2013, Added CPT modifier codes RT and LT to Table BCS-B and revised the optional exclusion for bilateral mastectomy to include instances where a mastectomy is performed on the right side and the left side of the body on the same date of service.

APPENDIX

Table BCS-A: Codes to Identify Breast Cancer Screening CPT Procedure Code Description 77055 Diagnostic , unilateral 77056 Diagnostic Mammography, bilateral 77057 Screening Mammography, bilateral HCPCS Description G0202 Screening mammography, producing direct digital image, bilateral, all views G0204 Diagnostic mammography, producing direct digital image, bilateral, all views

3/7/2014 Page 3 G0206 Diagnostic mammography, producing direct digital image, unilateral, all views ICD-9-CM Procedure Description 87.36 Xerography of breast 87.37 Other mammography UB Revenue Description 0401 MAMMOGRAPHY 0403 SCR MAMMOGRAPHY/GEN MAMMO

Table BCS-B: Codes to Identify Exclusions CPT Procedure Code Description 19180 Mastectomy, simple, complete 19200 Mastectomy, radical, including pectoral muscles, axillary lymph nodes 19220 Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes 19240 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle 19303 Mastectomy, simple, complete 19304 Mastectomy, subcutaneous 19305 Mastectomy, radical, including pectoral muscles, axillary lymph nodes 19306 Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes 19307 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle ICD-9-CM Procedure Description- Bilateral Mastectomy 85.42 Bilateral simple mastectomy 85.44 Bilateral extended simple mastectomy 85.46 Bilateral radical mastectomy 85.48 Bilateral extended radical mastectomy ICD-9-CM Procedure Description- Unilateral Mastectomy 85.41 Unilateral simple mastectomy 85.43 Unilateral extended simple mastectomy 85.45 Unilateral radical mastectomy 85.47 Unilateral extended radical mastectomy

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