Description:  The percentage of women 50–74 years of age who had a mammogram to screen for breast cancer.


Denominator:   Note: Members in hospice are excluded from the eligible population. Refer to General Guideline 20: Members in Hospice.


Product lines
Commercial, Medicaid, Medicare (report each product line separately).
Ages
Women 52–74 years as of December 31 of the measurement year.
Continuous enrollment
October 1 two years prior to the measurement year through December 31 of the measurement year.
Allowable gap
No more than one gap in enrollment of up to 45 days for each full calendar year of continuous enrollment (i.e., the measurement year and the year prior to the measurement year). To determine continuous enrollment for a Medicaid beneficiary for whom enrollment is verified monthly, the member may not have more than a 1-month gap in coverage during each full calendar year of continuous enrollment (i.e., the measurement year and the year prior to the measurement year).

No gaps in enrollment are allowed from October 1 two years prior to the measurement year through December 31 two years prior to the measurement year.
Anchor date
December 31 of the measurement year.
Benefit
Medical.
Event/diagnosis
None.


Denominator Exclusions (when applicable):  


Bilateral mastectomy any time during the member’s history through December 31 of the measurement year. 

Any of the following meet criteria for bilateral mastectomy:

  • Bilateral mastectomy (Bilateral Mastectomy Value Set).
  • Unilateral mastectomy (Unilateral Mastectomy Value Set) with a bilateral modifier (Bilateral Modifier Value Set).
  • Two unilateral mastectomies (Unilateral Mastectomy Value Set) with service dates 14 days or more apart. For example, if the service date for the first unilateral mastectomy was February 1 of the measurement year, the service date for the second unilateral mastectomy must be on or after
    February 15.
  • History of bilateral mastectomy (History of Bilateral Mastectomy Value Set).
  • Any combination of codes that indicate a mastectomy on both the left and right side on the same or different dates of service.
Left Mastectomy (any of the following)
Right Mastectomy (any of the following)
Unilateral mastectomy (Unilateral Mastectomy Value Set) with a left-side modifier
(Left Modifier Value Set) (same date of service)
Unilateral mastectomy (Unilateral Mastectomy Value Set) with a right-side modifier (Right Modifier Value Set) (same date of service)
Absence of the left breast (Absence of Left Breast Value Set)
Absence of the right breast (Absence of Right Breast Value Set)
Left unilateral mastectomy (Unilateral Mastectomy Left Value Set)
Right unilateral mastectomy (Unilateral Mastectomy Right Value Set)


Numerator:  One or more mammograms (Mammography Value Set) any time on or between October 1 two years prior to the measurement year and December 31 of the measurement year.