Remind Medicare Advantage members to get mammograms every two years

Breast cancer is one of the most common cancers among women in the U.S., according to the American Cancer Society. Yet 20 percent of female Medicare Plus Blue PPO members ages 50 to 74 haven’t had a mammogram in two years.

It’s important to remind your patients to have this preventive service done, and guide them through the procedure.

Recommended care

The HEDIS^® measure breast cancer screening is also used by the Centers for Medicare & Medicaid Services as a star rating measure to drive improvements in patient health.

Per CMS and HEDIS guidelines, routine mammograms are recommended every 24 months for women ages 50 to 74.

Communicating with patients

• Provide patients with a prescription for a mammogram and phone number to a local imaging center.
• Follow-up with patients to make certain they completed their screenings.
• Patients who have had bilateral mastectomies are excluded from the breast cancer screening measure.
• When you submit an office visit claim for patients with exclusions, please include the following ICD–10–CM diagnosis codes as appropriate:
• Z90.13 — Acquired absence of bilateral breasts and nipples
• Z90.12 — Acquired absence of left breast and nipple
• Z90.11 — Acquired absence of right breast and nipple
• Document completed mammogram date and exclusion criteria in the medical record.
• Send all eligible women a reminder card with information about the importance of routine mammograms and stress that it’s a covered preventive screening.

3D mammograms

Blue Cross Blue Shield of Michigan will now cover digital breast tomosynthesis - more commonly known as 3D mammography. It may be used as a screening or diagnostic modality in the assessment and management of breast cancer for individuals meeting certain criteria.

Coverage criteria

1. 3D mammograms may be used for screening when one of these criteria is met:
• It’s used in combination with digital screening mammography in high risk individuals
• An ordering provider or radiologist determines it should be the primary mammographic study
2. 3D mammograms may be used for screening or diagnostic purposes when:
• Digital mammography alone is inadequate or insufficient to support clinical decision-making, based on the radiologist reviewer’s opinion

Exclusions: Those not meeting the above criteria

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.