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Age Restriction Removed for Breast Cancer Diagnostic Procedure Codes for EWC

December 30, 2016

California’s Legislature recently passed Assembly Bill (AB) 1795 (Atkins, Chapter 68, Statutes of 2016) amending Section 104150 of the Health and Safety Code.

To comply with AB 1795, effective for dates of service on or after January 1, 2017, Every Woman Counts (EWC) will change eligibility policy regarding breast cancer diagnostic services. EWC will provide these services to symptomatic women under age 40.

Symptoms of breast cancer include but are not limited to the following:

  • Palpable mass or lumps in the breast
  • Changes in size or shape of the breast
  • Changes in skin texture or color (dimpling, puckering, redness, scaliness, or thickening) of the breast or nipple skin
  • Nipple retraction or inversion
  • Axillary lymphadenopathy or swelling
  • Nipple discharge
  • Breast pain

EWC-covered breast procedure codes will no longer have an age limit with the exception of screening mammography codes. Therefore, the following procedure codes retain the age restriction of 40 years of age and older.

CPT-4 Code Description
77057 Screening mammography, bilateral (2-view study of each breast)
HCPCS Code Description
G0202 Screening mammography, producing direct digital image, bilateral, all views

Manual replacement pages and all other EWC forms and documents will be released reflecting these changes in a future Medi-Cal Update.

For more information and to obtain the full list of covered breast cancer procedures, please refer to the Every Woman Counts section of the appropriate Part 2 manual.

To enroll symptomatic women under age 40, please refer to the Recipient Eligibility Form Addendum.

The CA-MMIS system is currently being updated to reflect this policy for EWC. Once the system is updated, all affected claims will be adjudicated and reprocessed in an Erroneous Payment Correction (EPC) in a timely manner, retroactive to January 1, 2017.

For additional information on AB 1795, EWC providers are recommended to consult the FAQ for AB 1795.

EWC providers are recommended to use Breast Cancer Diagnostic Algorithms for Primary Care Providers to facilitate the work of abnormal findings and women presented with symptoms.