WCHQ Ambulatory Measure Specification
WCHQ 18 – Preventative Care: Breast Cancer Screening
Measurement Period 01/01/2014 - 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
MEASURE DESCRIPTION
The percentage of women age 50 through 74 who had a minimum of one breast cancer screening
test during the two year measurement period. (Refer to Table M-3 for qualifying tests)
Disclaimer: Measures reported by WCHQ healthcare organizations represent a specific aspect of care in
relation to an evidence-based standard, but are not clinical guidelines and do not establish standards of care.
All providers should have an individual care plan established with their patient.
GENERAL INFORMATION / RATIONALE
The United States Preventive Services Task Force (USPSTF) encourages individualized, informed
decision-making about when to start mammography screening. The updated USPSTF
recommendation endorses this approach to deciding when to start screening. The precise age at
which the benefits from screening mammography justify the potential harms, is a subjective
judgment and should take into account patient preferences.
There is convincing evidence that screening with film mammography reduces breast cancer
mortality, with a greater absolute reduction for women aged 50 to 74 years than for women aged
40 to 49 years. The strongest evidence for the greatest benefit is among women aged 60 to 69
years. Among women 75 years or older, evidence of benefits of mammography is lacking.¹
For women who have had sporadic breast cancer the evidence supports regular history, physical
examination, and mammography as the cornerstone of appropriate breast cancer follow-up.
Women treated with breast-conserving therapy should have their first post-treatment mammogram
no earlier than 6 months after definitive radiation therapy. Subsequent mammograms should be
obtained every 6 to 12 months for surveillance of abnormalities. Mammography should be
performed yearly if stability of mammographic findings is achieved after completion of loco regional
therapy.²
References
1.
United States Preventive Services Task Force (USPSTF). Screening for breast cancer: Recommendation
update (2009, December). Retrieved October 26, 2010 from:
http://www.uspreventiveservicestaskforce.org/uspstf09/breastcancer/brcanrs.htm#clinical
2.
Khatcheressian, J. L., Wolff, A.C., Smith, T.J., Grunfeld, E., Muss, H. B., Vogel, V.G., Halberg, F., Somerfield,
M.R., & Davidson, N.E. (2006). Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting. J
Clin Oncol ( 24), 5091-97. Retrieved October 26, 2010 from:
http://jco.ascopubs.org/content/24/31/5091.full.pdf+html
DEFINITIONS
24 Months: Measurement Period
36 Months: Measurement Period plus Prior Year
Primary Care Office Visit: Office visit in an outpatient, non-urgent care setting
PCP: For WCHQ measure purposes, a primary care provider is defined as any General Practice,
Internal Medicine, Family Practice, Pediatrics provider with the following degree types (MD, DO,
PA, NP) and any other practitioners identified by the healthcare system as primary care
practitioners. The rationale for the additional practitioner(s) must be documented and must be
applied consistently across all measures by the organization.
Measure Specific Specialist: As part of the denominator population for this measure visits to an
OB-GYN qualify as office visits for the denominator population.
Age Range 50 - 74: Patients born between 01/01/1941 – 01/01/1965
Breast Cancer Screening – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
1
WCHQ Ambulatory Measure Specification
WCHQ 18 – Preventative Care: Breast Cancer Screening
Measurement Period 01/01/2014 - 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
DENOMINATOR DESCRIPTION
Women whose age at the beginning of the two year measurement period is at least 50 and whose
age at the end of the two year measurement period is less than 75, and who are alive as of the last
day of the Measurement Period. Expired patients for whom a specific date of expiration cannot be
found are excluded from the denominator population.
The rationale for the denominator population is built from the following criteria:
[Question 1] – Is this a patient whose care is managed within the physician group?
[Question 2] – Is this a patient currently managed in our system?
[Question 3] – Is this a patient that is eligible for a mammogram?
ENCOUNTER DATA
Patients eligible for inclusion in the denominator include:
[Question 1] – Is this a patient whose care is managed within the physician group?
Patients who had at least two Primary Care office visits (Table M-1), regardless of
diagnosis code, on different dates of service, to a PCP and/or OB-GYN provider in the past
36 months (Eligibility Window). If OB-GYN is not considered a PCP, at least one of the two
office visits must be to a PCP.
[Question 2] – Is this a patient currently managed in our system?
Patients who had at least one Primary Care office visit (Table M-1) regardless of diagnosis
code, with a PCP and/or OB-GYN provider in the most recent 24 months (Measurement
Period).
[Question 3] – Is this a patient that is eligible for a breast cancer screening?
Exclude those who have had a bilateral mastectomy OR a unilateral mastectomy or those
with trans-gender status (Table M-2). The organizations may look for these exclusions as
far back as possible in the patient’s history, through administrative data and/or medical
record review. The exclusion can be identified through an ICD-9 diagnosis-based problem
list. The problem must be ACTIVE. There is no limit on the look back date, but the date of
documentation or onset date must occur prior to the end of the measurement period.
NOTE: A patient who has had a partial mastectomy/lumpectomy will be included within the
denominator.
NUMERATOR DESCRIPTION
The number of eligible women who had one or more breast cancer screening tests during the two
year Measurement Period as demonstrated through any of the following:

Administrative data, which can include:
o Table M-3
Breast Cancer Screening – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
2
WCHQ Ambulatory Measure Specification
WCHQ 18 – Preventative Care: Breast Cancer Screening
Measurement Period 01/01/2014 - 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
o
Internal, external and/or patient reported screenings extracted electronically from an
Electronic Medical Record (EMR), requiring one of the following:
 Year test was performed
 Date range test was performed, providing the entire range is within the
measurement period.
NOTE: This does not include results with a date of documentation only; the actual
year or date range of the test must be present and be within the numerator
description timeframes for inclusion in the numerator.

Medical Record Review (Refer to Medical Record Review for Numerator
Inclusion/Denominator Exclusion section)
Breast Cancer Screening – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
3
WCHQ Ambulatory Measure Specification
WCHQ 18 – Preventative Care: Breast Cancer Screening
Measurement Period 01/01/2014 - 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
INTERNALLY DEVELOPED CODES – DATA TRANSLATION / MAPPING REQUIREMENTS
If a medical group utilizes internally generated codes to identify specific services or events required
for a given WCHQ performance measure, the group may translate or map the information to the
WCHQ performance measurement specifications. The medical group must assure that the
internally generated code matches the clinical specificity of the standard (ICD-9, CPT) codes
included in the WCHQ performance measurement specifications.
In order to use internally developed codes for WCHQ performance measure reporting, the medical
group needs to document the translation/mapping to the codes in the specifications. This
documentation should include the internally generated code, a description of the internally
developed code, any additional clinical information for the internally developed code, and the
equivalent standard code with description from the WCHQ performance measurement
specifications. Once the translation/ mapping documentation is established, the medical group’s
WCHQ performance measurement team must review the mapping on a yearly basis and document
that internally developed codes have not changed and are being used in the manner described in
the translation/ mapping document.
The medical group must have documented processes in place for adding codes to the medical
group’s administrative data system and procedures to implement the internally developed codes.
MEDICAL RECORD REVIEW FOR NUMERATOR INCLUSION / DENOMINATOR EXCLUSION
If appropriate, and/or when necessary, every organization may complement their electronic capture
of patient medical history with electronic or manual record review. The following criteria apply only
to data captured/reviewed during medical record review.
Numerator Inclusion
For WCHQ Preventive Screening Measures, which can include, internal, external, and/or patient
reported test results, proof of numerator compliance requires one of the following:
 Year test was performed
 Date range test was performed, providing it is within the measurement period.
NOTE: This does not include results with a date of documentation only; the actual year or date
range of the test must be present and be within the numerator description timeframes for
inclusion in the numerator.
Denominator Exclusion
For all WCHQ Measures, proof of Denominator exclusion requires:
 Existence of exclusion criteria.
These data may be retrieved, in whole or in part, from any of the following:
 Notation in Progress Note
 Notation in Medical History or Surgical History
 Flag/Field in Electronic Medical Record
 Documentation in patient chart
REQUIRED DATA SUBMISSION FIELDS
Fields required for data submission for this measure depend upon the methodology used. The
fields are as follows:
Breast Cancer Screening – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
4
WCHQ Ambulatory Measure Specification
WCHQ 18 – Preventative Care: Breast Cancer Screening
Measurement Period 01/01/2014 - 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
Organization Level Reporting:
TOTAL POPULATION METHODOLOGY:
 Population Denominator (N) (Patients Eligible for Breast Cancer Screening)
 Numerator (Patients who had a minimum of one Breast Cancer Screening)
Upon entry of these numbers, the rate is automatically calculated
FIELDS REQUIRED FOR MEASURE VALIDATION
Validation of this measure will require patient level data samples for Administrative/EMR Data and
patient level data collection tool samples for Manual Review. The following indicates fields needed
for validation, which may be helpful to consider when querying the measure:
Denominator Data Sample fields:
 Patient Identifier (can be medical record number or other ID)
 Primary Care Office Visit Dates
 Provider Specialty
 Patient Date of Birth
 Patient Gender
 Exclusion codes used for Mastectomy or transgender status
 Date of Mastectomy or transgender status or date of documentation
Numerator Data Sample fields:
Numerator data sample is from denominator data sample
 Patient Identifier (can be medical record number or other ID)
 Mammogram or other breast cancer screening code or test description
 Test Date (Specific Date, Year or Date Range)
Breast Cancer Screening – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
5
WCHQ Ambulatory Measure Specification
WCHQ 18 – Preventative Care: Breast Cancer Screening
Measurement Period 01/01/2014 - 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
Appendix A
Primary Payer
In keeping with the changing atmosphere of quality measurement and reporting, WCHQ would like
for participating organizations to include the primary payer source with their data submissions for
the ambulatory care measures.
The primary payer source should be identified in the denominator upon answering the question, “Is
this patient current in our system?” Once it has been determined that a patient is current because
of a visit to their physician within the specified time period (12 months for chronic care measures
and 24 months for preventive care measures), the payer should be “pulled” into the query. The
primary payer should be the payer at the most recent office visit within the measurement period.
There will be four categories of primary payer that will need to be submitted to WCHQ via the data
submission tool: Medicare FFS, Medicaid (all types), Commercial (including Medicare HMO) and
Uninsured/Self-Pay. The raw numbers for the denominator and numerator should be included for
all three types of data submission, total population, hybrid, and sample.
Rationale
Opportunities exist for WCHQ to collect and report data on specific populations, like the Medicare
population, through grant applications to begin to understand the disparities in quality of care. The
purpose of this is to begin to understand the challenges of putting in additional data elements and
complexities of data display for public reporting. At this time, the primary payer information will not
be publicly reported.
Definitions:
Commercial: All plans not Medicaid or Medicare FFS (Includes VA, DoD, etc.)
FFS Medicare: FFS plans, not Medicare HMO (Medicare Railroad is FFS Medicare)
Medicaid: All Medicaid plans including those managed by commercial plans
Uninsured: Self-pay individuals
Breast Cancer Screening – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
6
WCHQ Ambulatory Measure Specification
WCHQ 18 – Preventative Care: Breast Cancer Screening
Measurement Period 01/01/2014 - 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
APPENDIX B
TABLE M-1: Office Visit Encounter Codes (Outpatient)
CPT Codes
Description
a
99201-99205
99212-99215
99241-99245
99347-99350
99384-99387
99394-99397
99401-99404
99411
99412
99420
99429
Office or OP visit E&M , new patient
Office or OP visit E&M, established patient
Office or other OP consultations
Home visit for evaluation and management of an established patient
Initial preventive medicine E&Mb
Periodic preventive medicine E&Mb
Preventive medicine counseling
Preventive medicine counseling, group
Preventive medicine counseling, group
Risk assessment, admin and interpretation
Unlisted preventive medicine service
HCPCS Code
G0344
(effective 01/01/2005)
G0402
(Effective 01/01/09)
G0438
G0439
a
b
b
Description
Initial preventive physical examination; face-to-face visit services
limited to new beneficiary during the first six months of Medicare
enrollments
Initial preventive physical examination; face-to-face visit, services
limited to new beneficiary during the first 12 months of Medicare
enrollment
Annual wellness visit; includes a personalized prevention plan of
service, initial visit
Annual wellness visit; includes a personalized prevention plan of
service, subsequent visit
outpatient
evaluation and management
TABLE M-2: Codes to Identify Exclusions for Breast Cancer Screening
ICD-9-CM
Diagnosis
Codes
Description
**V45.71
**V51.0
Acquired absence of the breast and nipple
Encounter for breast reconstruction following mastectomy
V50.41
**Codes can be included at the organization’s discretion. If included, chart
review is required for these visits.
Prophylactic Removal of Breast
302.5x
Trans-sexualism
302.50
Trans-sexualism with unspecified sexual history
302.51
Trans-sexualism with asexual history
302.52
Trans-sexualism with homosexual history
Breast Cancer Screening – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
7
WCHQ Ambulatory Measure Specification
WCHQ 18 – Preventative Care: Breast Cancer Screening
Measurement Period 01/01/2014 - 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
302.53
**302.85
Trans-sexualism with heterosexual history
Gender identity disorder in adolescents or adults
**Code can be included at the organization’s discretion. If included, chart
review is required for these visits.
Effective 10/01/2015
ICD-10-CM
Diagnosis
Codes
**Z90.10
**Z90.11
**Z90.12
**Z90.13
**Z42.1
Z40.01
F64.1
Z87.890
Description
Acquired absence of unspecified breast and nipple
Acquired absence of right breast and nipple
Acquired absence of left breast and nipple
Acquired absence of bilateral breasts and nipples
Encounter for breast reconstruction following mastectomy
**Codes can be included at the organization’s discretion. If included, chart
review is required for these visits.
Encounter for prophylactic removal of breast
Gender identity disorder in adolescence and adulthood
Personal history of sex reassignment
ICD-9-CM
Procedure
Codes
85.4x
85.41
85.42
85.43
85.44
85.45
85.46
85.47
85.48
62.4x
62.41
62.42
64.3
64.5
Description
Mastectomy
Unilateral simple mastectomy
Bilateral simple mastectomy
Unilateral extended simple mastectomy
Bilateral extended simple mastectomy
Unilateral radical mastectomy
Bilateral radical mastectomy
Unilateral extended radical mastectomy
Bilateral extended radical mastectomy
Bilateral orchiectomy
Removal of both testes at same operative episode
Removal of remaining testis
Amputation of penis
Operation for sex transformation, not otherwise classified
Effective 10/01/2015
ICD-10-CM
Procedure
Codes
0HTT0ZZ
0HTU0ZZ
0HTV0ZZ
07T50ZZ
07T60ZZZ7T
Description
Resection of Right Breast, Open Approach
Resection of Left Breast, Open Approach
Resection of Bilateral Breast, Open Approach
Resection of Right Axillary Lymphatic, Open Approach
Resection of Left Axillary Lymphatic, Open Approach
Breast Cancer Screening – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
8
WCHQ Ambulatory Measure Specification
WCHQ 18 – Preventative Care: Breast Cancer Screening
Measurement Period 01/01/2014 - 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
0KTH0ZZ
0KTJ0ZZ
07T70ZZ
07T80ZZ
07T90ZZ
0VTC0ZZ
0VTC4ZZ
0VTS0ZZ
0VTS4ZZ
0VTSXZZ
0W4M070
0W4M0J0
0W4M0K0
0W4M0Z0
0W4N071
0W4N0K1
0W4N0K1
0W4N0Z1
Resection of Right Thorax Muscle, Open Approach
Resection of Left Thorax Muscle, Open Approach
Resection of Thorax Lymphatic, Open Approach
Resection of Right Internal Mammary Lymphatic, Open Approach
Resection of Left Internal Mammary Lymphatic, Open Approach
Resection of Bilateral Testes, Open Approach
Resection of Bilateral Testes, Percutaneous Endoscopic Approach
Resection of Penis, Open Approach
Resection of Penis, Percutaneous Endoscopic Approach
Resection of Penis, External Approach
Create Vagina in Male Perineum with Autol Sub, Open
Create Vagina in Male Perineum with Synth Sub, Open
Create Vagina in Male Perineum with Nonaut Sub, Open
Creation of Vagina in Male Perineum, Open Approach
Create Penis in Female Perineum with Autol Sub, Open
Create Penis in Female Perineum with Synth Sub, Open
Create Penis is Female Perineum with Nonaut Sub, Open
Creation of Penis in Female Perineum, Open Approach
CPT Codes
19180
Description
Mastectomy, simple, complete
(Deleted January 1,
2007 and replaced
with 19303)
19182
Mastectomy, subcutaneous
(Deleted January 1,
2007 and replaced
with 19304)
19200
Mastectomy, radical, including pectoral muscles, axillary lymph nodes
(Deleted January 1,
2007 and replaced
with 19305)
19220
(Deleted January 1,
2007 and replaced
with 19306)
19240
(Deleted January 1,
2007 and replaced
with 19307)
19303
19304
19305
19306
19307
.50 and 09950
modifier codes
Mastectomy, radical, including pectoral muscles, axillary and internal
mammary lymph nodes (Urban type operation)
Mastectomy, modified radical, including axillary lymph nodes, with or without
pectoralis minor muscle, but excluding pectoralis major muscle
Mastectomy, simple, complete
Mastectomy, subcutaneous
Mastectomy, radical, including pectoral muscles, axillary lymph nodes
Mastectomy, radical, including pectoral muscles, axillary and internal
mammary lymph nodes (Urban type operation)
Mastectomy, modified radical, including axillary lymph nodes, with or without
pectoralis minor muscle, but excluding pectoralis major muscle
Use of these modifier codes with any of the above CPT Codes indicate the
procedure was bilateral and performed during the same operative session.
Breast Cancer Screening – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
9
WCHQ Ambulatory Measure Specification
WCHQ 18 – Preventative Care: Breast Cancer Screening
Measurement Period 01/01/2014 - 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
55970
55980
Intersex surgery male to female
Intersex surgery female to male
TABLE M-3: Codes to Identify Breast Cancer Screening
Description
CPT / HCPCS
Codes
77055
77056
77057
77058
77059
C8903
C8904
C8905
C8906
C8907
C8908
G0202
G0204
G0206
Diagnostic mammography, unilateral
(Note: Added January 1, 2007)
Diagnostic mammography, bilateral
(Note: Added January 1, 2007)
Screening mammography, bilateral (two film study of each breast)
(Note: Added January 1, 2007)
Magnetic resonance imaging breast, without and/or with contrast material(s);
unilateral
Magnetic resonance imaging breast, without and/or with contrast material(s);
bilateral
Magnetic resonance imaging with contrast, breast; unilateral
Magnetic resonance imaging without contrast
Magnetic resonance imaging without contrast followed by with contrast,
breast; unilateral
Magnetic resonance imaging with contrast, breast; bilateral
Magnetic resonance imaging without contrast, breast; bilateral
Magnetic resonance imaging without contrast followed by with contrast,
breast; bilateral
Screening mammography, digital, bilateral
Diagnostic mammography, digital, bilateral
Diagnostic mammography, digital, unilateral
ICD-9-CM
Diagnosis
Codes
**V76.11
**V76.12
Description
Screening mammogram for high risk patient
Other screening mammogram
**Codes can be included at the organization’s discretion. If included, chart
review is required for these visits.
Effective 10/01/2015
ICD-10-CM
Diagnosis
Codes
**Z12.31
Description
Encounter for screening mammogram, malignant neoplasm of breast
**Codes can be included at the organization’s discretion. If included, chart
review is required for these visits.
Breast Cancer Screening – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
10
WCHQ Ambulatory Measure Specification
WCHQ 18 – Preventative Care: Breast Cancer Screening
Measurement Period 01/01/2014 - 12/31/2015
Process Measure Type
NQS Domain: Clinical Process/Effectiveness
ICD-9-CM
Procedure
Codes
87.36
87.37
Description
Xerography of breast (radiographic exam of breast via selenium-coated
plates)
Other mammography
Effective 10/01/2015
ICD-10-CM
Procedure
Codes
BH00ZZZ
BH01ZZZ
BH02ZZZ
BH03ZZZ
BH04ZZZ
BH05ZZZ
BH06ZZZ
Description
Plain Radiography of Right Breast
Plain Radiography of Left Breast
Plain Radiography of Bilateral Breasts
Plain Radiography of Right Single Mammary Duct
Plain Radiography of Left Single Mammary Duct
Plain Radiography of Right Multiple Mammary Ducts
Plain Radiography of Left Multiple Mammary Ducts
Description
UB-92
Revenue
Codes
401
403
Mammography
Screening mammography
Breast Cancer Screening – QCDR Non-PQRS Measure 2014
This specification is updated annually; refer to previous versions for coding and other changes
11