September 2019

Mammography Screening for Early Detection of Breast Cancer

In 2018, the American Cancer Society (ACS) estimated that around 266,000 new cases of breast cancer in women were reported and about 41,000 of those resulted in mortality.¹ The best defense for survival is early detection through screening. The U.S. Preventive Services Task Force (USPSTF) recommends annual breast cancer screening, and in most patient situations, the National Comprehensive Cancer Network and ACS agree.

Breast cancer screening is a Healthcare Effectiveness Data and Information Set (HEDIS^®) measure. HEDIS was developed and is maintained by the National Committee for Quality Assurance (NCQA) to standardize and measure quality for all patients. The Office of Personnel Management (OPM) reviews HEDIS performance of certain measures for Federal Employee Program^® (FEP^®) members.

Strategies for improving HEDIS measure for breast cancer screening include:

• Utilizing NCQA coding tips to actively reflect care rendered.
• Educating women, starting at age 50, about the importance of early detection and treatment.
• Referring women to local mammography imaging centers and following up to verify completion.
• Using reminder systems for check-ups and screenings.

Blue Cross and Blue Shield of Illinois (BCBSIL) FEP members who are female and 40 years old and older are eligible for one breast cancer screening per calendar year as a covered benefit. Mammography screenings are part of the FEP’s preventive care benefits and are recognized by the plan on the first claim processed in a calendar year, regardless of when in the previous calendar-year the screening exam was performed. Preventive care benefits include unilateral or bilateral mammography screening or digital breast tomosynthesis screening.

For information purposes only, the below chart shows Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT^®) codes for your review and easy access when designating mammography screening for early detection of breast cancer. For a complete list, please refer to the NCQA website.

Thank you for your dedication to help ensure that all your patients including FEP members receive exceptional care. If you have any questions regarding FEP members, please do not hesitate to reach out to the Federal Employee Quality Improvement Program.

¹ American Cancer Society, How Common Is Breast Cancer? January 2019. https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html

HEDIS is a registered trademark of NCQA.

CPT copyright 2018 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to other third party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.