HEDIS® Tip Sheet

Breast Cancer Screening (BCS)

Line of business: BlueAlliance (Commercial) & BlueAlliance Care+ (Medicaid)

Measure Description

Percentage of Members 40-74 years of age who had a mammogram to screen for breast cancer.

Compliance:

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.

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Notes

  • MRI’s, ultrasounds, and/or biopsies do not count toward compliance for this measure.
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Medical Records should include

  • Documentation of the date the mammogram was performed.
  • Documentation of the medical and surgical history (e.g., mastectomy) and dates performed. 
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Best Practices

  • Engage in state programs such as ScreeND.
  • Establish an annual standing order for eligible population.
  • Utilize EMR reporting and patient flags for those in need of screening.
  • Engage providers in consistent messaging.
  • Provide mammography outreach in rural areas.
  • Organize women’s health fairs.
  • Implement self-scheduling.
  • Keep appointment slots open each day to allow for same-day visits.
  • Collaborate with radiology department to provide outreach to patients eligible for screening.
  • Create/participate in a Women’s Health Event which includes breast cancer screening.
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Exclusions

  • History of bilateral mastectomy on both the left and right side or both right and left unilateral mastectomies any time during the member’s history through the end of the measurement period.
  • Members who had gender-affirming chest surgery with a diagnosis of gender dysphoria anytime in the members history.
  • Members in hospice during the measurement year.
  • Members receiving palliative care during the measurement year.
  • Members 66+ years of age with frailty and advanced illness.
    Note: Members must meet BOTH the frailty and advanced illness criteria to be excluded:
    • At least two indicators of frailty with different dates of service during the measurement period.
    • Any of the following during the measurement year or the year prior to the measurement year:
      • At least two outpatient visits, observation visits, ED visits, telephone visits, e-visits, or virtual check-ins, nonacute inpatient encounters, or nonacute inpatient discharges on different dates of service with an advanced illness diagnosis.
      • At least on acute inpatient encounter with an advanced illness diagnosis.
      • At least one acute inpatient discharge with an advanced illness diagnosis on the discharge claim.
      • A dispensed dementia medication. 

Mammography Codes



Coding Disclaimer

The analysis of any medical coding question related to a measure is dependent on the measure’s technical specifications including the factual situations present related to the member, the practice, the professionals, and the medical services provided.

Questions  

Should you have specific coding or other questions related to the measure, please send your questions to BlueAlliance@bcbsnd.com.

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Updated 1/22/2025