BCBSRI is committed to making it easier for your practice to be successful in all areas of quality improvement. Together, we can achieve our shared goal of improving health outcomes by identifying and addressing open care gaps.

Hints for HEDIS (and more) is a reference tool developed to explore various quality topics, including:

• Definitions, specifications, and exclusions of the many quality measures;
• Billing codes used to report gap closure;
• Collection and reporting methodologies; and
• Tips and best practices to maximize gap closure.

Our Quality Concierge Team (QCT) is also available to answer questions, provide updates, assist in the interpretation of monthly gap in care reports, and provide overall HEDIS support to you and your practice. Reach our QCT nurses by emailing QualityHEDIS@bcbsri.org or calling (401) 459-1005.

Breast cancer screening

Breast cancer is the most common cancer among American women, regardless of race or ethnicity. Breast cancer screening can improve outcomes, as early detection reduces the risk of dying from breast cancer. Early detection can also lead to a greater range of treatment options and lower healthcare costs. See these HEDIS measures for breast cancer screening.

We know screenings are down, as many mammograms were cancelled or postponed to decrease exposure to COVID-19. As restrictions begin to be lifted, we want our members to have the best options for breast cancer screening.

Mammograms are vital for prevention and detection of breast cancer. It is recommended that women 50–74 years of age have a breast cancer screening at least every two years. The type and method of mammography should be discussed with the member, and a possible specialist referral may be appropriate to fit the member’s needs. MRIs, ultrasounds, or biopsies do not close the HEDIS gap in care.

Many women with breast cancer do not have symptoms, which is why regular breast cancer screenings are so important. PCPs should discuss the importance of early detection and encourage testing. Possible fears about mammography should also be discussed, and members should be informed that current testing methods are less painful and require less radiation.

Best practices:

• It is helpful to have a list of mammogram facilities available to share with members.
• Review and document patient history annually regarding breast cancer screening.

Measurement period:

Date of service between October 1, 2018-December 31, 2020.

Exclusions:

• Members 65 years of age and older living in a long-term institutional setting, or with advanced illness and/or frailty.
• Members enrolled in hospice.
• Bilateral mastectomy any time during the member’s history. Any of the following meet criteria:
  • Bilateral mastectomy
  • Unilateral mastectomy with bilateral modifier
  • Unilateral mastectomy found in clinical data with a bilateral modifier
• Both of the following on the same or different dates of service:
  • Unilateral mastectomy with a left-sided modifier
  • Unilateral mastectomy with a right-sided modifier

Closing the gap

The following claims information and/or medical record documentation count as compliant:

• Receipt of a claim for mammogram from the radiology facility where the mammogram was performed
• Claim with CPT Cat II code 3014F “Screening for Mammography” documented and reviewed
• All screenings documented in the medical record must indicate the specific date and result