Frequently Asked Questions & Concerns for AB ​1795 

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. 

​​​​​​​​Documents

• Download the Recipients Eligibility Form Addendum (For Spanish Version)
• Download the Provider Information Notice​