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EWC: Erroneous Payment Correction Planned for Breast Screening/Diagnostic Services

June 6, 2017

Every Woman Counts (EWC) providers are encouraged to submit claims for breast cancer screening and diagnostic services for symptomatic recipients 40 years of age or younger per Assembly Bill (AB) 1795 (Atkins, Chapter 608, Statutes of 2016) amending Section 104150 of the Health and Safety Code.

The Medi-Cal claims processing system is being updated to handle claims for recipients in this age range. Once the system is ready, claims previously submitted for breast screening/diagnostic services provided to individuals younger than 40 years of age, with dates of service on or after January 1, 2017, and that have been denied for age restrictions, will be subject to an Erroneous Payment Correction (EPC).

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

Per AB 1795, EWC-covered breast screening and diagnostic services 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

The full list of covered breast cancer procedures is included in the Every Woman Counts section of the appropriate Part 2 manual.

To enroll symptomatic women 40 years of age or younger, EWC Primary Care Providers (PCPs) should use the Recipient Eligibility Form Addendum.

PCPs are reminded that according to EWC requirements all data for every diagnostic event/cycle should be submitted via online data entry system DETEC (DETecting Early Cancer) within 30 days of receipt, regardless of results.

Additional information about AB 1795 is available on the Frequently Asked Questions & Concerns for AB 1795 Web page of the Department of Health Care Services (DHCS) website.

Provider manual and EWC document updates will be announced in a future Medi-Cal Update.