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Frequently Asked Questions & Concerns for AB ​1795 

California’s Legislature recently passed AB 1795 (Atkins, Chapter 68, Statutes of 2016), which amends Sections 104150 and 104161.1 of the Health and Safety Code (HSC), effective January 1, 2017.
For dates of service on or after January 1, 2017, EWC will provide diagnostic services to symptomatic women under age 40.
 

Frequently Asked Questions

 

1.    What is the difference between screening and diagnostic mammograms?

 
Screening mammograms are routinely administered to detect breast cancer in women who have no apparent symptoms. Diagnostic mammogram includes supplemental mammographic views and a possible ultrasound. Diagnostic mammogram is indicated if:
·         A patient has signs and/or symptoms of breast cancer which alert the physician to check the tissue; and/or
·         An abnormality is found on screening mammogram.
 
2.    What are symptoms of breast cancer?
 
Warning signs and/or symptoms of breast cancer include, but are not limited to:
·         Palpable mass, lump or swelling in the breast or the underarm;
·         Changes in size or shape of the breast;
·         Change in skin texture and color (dimpling, puckering, redness, scaly skin,
or thickening) of the breast or nipple;
·         Nipple retraction or inversion;
·         Nipple discharge; and/or
·         Breast pain.
Please note that these warning signs and/or symptoms may occur with conditions other than breast cancer.                                  
 
3.    Will there be a lower age limit for provision of breast diagnostic services?
 
No, there are no age restrictions.
 
4.    Will EWC cover screening for women who are high risk?
 
This is beyond the scope of AB 1795.
 
5.    How will providers indicate that a woman under age 40 qualifies for diagnostic testing?
 
In order for claims to be paid, providers must provide the appropriate breast diagnostic Current Procedural Terminology (CPT) code(s) in conjunction with corresponding ICD-10 code(s).  All breast cancer diagnostic codes are covered for women under age 40. For more information, please refer to the EWC section of the Medi-Cal Provider Manual, “ev woman”.
 
6.    Will the Recipient Identification (ID) cards and the EWC portion of the Provider Manual (“ev woman”) be updated to reflect the policy changes?
 
Yes, all EWC documents and publications, including the Recipient ID Card and EWC portion of Medi-Cal Provider Manual (“ev woman”), are currently in the process of being updated to reflect the new policy.
 
7.    Will office visit CPT codes 99204 and 99214 have age limits?
 
No, CPT codes 99204 and 99214 will not have age restrictions.
 
8.    Will data collection and submission for their breast diagnostic work-up be required for this age group?
 
Yes.
 
9.    When will Medi-Cal be ready to process these claims?
 
The claims adjudication system is currently being updated, which may take up to 90 days.  Once the system is updated, all claims will be adjudicated and processed in a timely manner, retroactive to January 1, 2017.
 

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Last modified on: 7/17/2017 9:17 AM