Knowledge Base Article

“He’s making a list and he’s checking it twice.” Are you a list maker like Santa? If so, you probably have more lists at this time of the year than usual – gift lists, shopping lists, decorating to-do lists, and family/social gatherings lists. Can you handle one more list? There is a list of requirements and information for Medicare coverage of lung cancer screening by Low Dose CT.

Medicare recently added a new preventive service for Medicare beneficiaries through the National Coverage Determination (NCD) process that allows coverage of additional preventive services that are reasonable and necessary for the prevention or early detection of illness or disability. Medicare now covers lung cancer screening by Low Dose Computed Tomography (LDCT). This is an important preventive service since lung cancer was expected to claim over 158,000 lives in the United States in 2015.

A new HCPCS procedure code to bill Medicare for this service was finally announced in the 2016 OPPS Final Rule. Providers also need to carefully review the numerous requirements of the NCD and the claim processing instructions. Medicare summarizes all of these requirements in MLN Matters Article MM9246. Review our list of 8 issues concerning LDCT lung cancer screening to make sure you know what needs to be checked off when providing this service.

1.Dates

Lung cancer screening by LDCT is covered annually for services performed on and after February 5, 2015. The implementation date is January 4, 2016. This means Medicare will begin processing claims with the new HCPCS codes on and after this date. Timely filing limits will apply so claims must be submitted within one year of the date of service. So if your facility began providing this service last February, you will need to hurry after the first of 2016 to get your claims to Medicare before your time runs out.

2.Patient Coverage Criteria

• Age 55-77 years
• Asymptomatic (no signs or symptoms of lung cancer)
• Tobacco smoking history of at least 30 pack-years (one-pack year = smoking one pack (20 cigarettes) per day for one year)
• Current smoker or one who has quit within last 15 years
• Receives a written order provided at
• a lung cancer screening counseling and shared decision making visit for the first screening
• any appropriate visit with a practitioner for subsequent screening

3.Written Order Requirements

Written orders for lung cancer LDCT screenings must be appropriately documented in the beneficiary’s medical records, and must contain the following information:

• Patient’s date of birth
• Number of actual pack-year smoking history
• Current smoking status and the number of years since quitting for former smokers
• Statement that patient is asymptomatic
• NPI of ordering practitioner

4.Counseling and Shared Decision Making Visit

The lung cancer screening counseling and shared decision making visit may be billed by a hospital on a type of bill 12x, 13x, or 85x (CAH). The counseling visit must:

• Be furnished by a physician or qualified non-physician practitioner (meaning a Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) and
• Include all of the following elements:
• Determination of beneficiary eligibility including age, absence of signs or symptoms of lung cancer, a specific calculation of cigarette smoking pack-years; and if a former smoker, the number of years since quitting;
• Shared decision-making, including the use of one or more decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure;
• Counseling on the importance of adherence to annual lung cancer LDCT screening, impact of co-morbidities, and ability or willingness to undergo diagnosis and treatment;
• Counseling on the importance of maintaining cigarette smoking abstinence if former smoker; or the importance of smoking cessation if current smoker and, if appropriate, furnishing of information about tobacco cessation interventions; and,
• If appropriate, the furnishing of a written order for lung cancer screening with LDCT.

5.Other Coverage Requirements

The NCD also contains specific requirements for eligibility criteria for the reading radiologist and the radiology imaging facility. The imaging facility criteria include data submission to a CMS-approved registry.

6.HCPCS Codes

• G0296 –Counseling visit to discuss need for lung cancer screening (LDCT) using low dose CT scan (service is for eligibility determination and shared decision making)
• G0297 –Low dose CT scan (LDCT) for lung cancer screening

7.Diagnosis and Diagnosis Code Required for Coverage

Personal history of tobacco use/personal history of nicotine dependence

• ICD-9 code V15.82 (for dates of service from February 5 – September 30, 2015)
• ICD-10 code Z87.891 (for dates of service on and after October 1, 2015)

8.Hospital Payment and Waiver of Co-insurance/Deductible

Lung cancer screening provided in a hospital outpatient setting is paid under OPPS and there is no beneficiary deductible or co-payment. The unadjusted Medicare payment amount for 2016 is $69.65 for G0296 (counseling visit) and $112.49 for G0297 (LDCT scan).

9.Frequency

LDCT for lung cancer screening is covered once per year. At least 11 full months must elapse from the date of the last screening.

The links to the actual transmittals that are listed in the MLN Matters Article do not appear to be working. You can find the full transmittals at: CMS Transmittal R3374CP and CMS Transmittal R185NCD . So get busy checking off that list!