Ldct chest for lung cancer screening cpt code

Effective July 1, 2019, providers may request, perform and bill for low-dose lung cancer screening utilizing healthcare common procedure coding system (HCPCS) code G0297 (low-dose CT scan [LDCT] for lung cancer screening). This service was previously requested and performed under current procedural terminology (CPT) code 71250 (computed tomography, thorax; without contrast material). Prior approval is dependent on the beneficiary’s eligibility at the time of service. Please refer to clinical coverage policy 1K-7, (which can be accessed at: https://medicaid.ncdhhs.gov/providers/clinical-coverage-policies/radiology-clinical-coverage-policies) prior approval for imaging services, for information regarding PA requirements. G0297 will also be available to perform and bill in the IDTF setting.

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National coverage for lung cancer screening has arrived. In February 2015, Centers for Medicare & Medicaid Services (CMS) issued a final coverage policy. Heretofore, screening programs have had varying levels of success in attracting providers and patients alike with the major barrier being lack of reimbursement. The purpose of this discussion is separate from the utility of screening. Rather, the focus is on obtaining coverage for the patient encounters and scans required. The Affordable Care Act and the CMS lung cancer screening policy significantly change coverage.

There are 2 main areas to understand, CMS coverage and commercial carrier coverage.

CMS Coverage

From a CMS perspective, we can take the specific criteria from their announcement.1 The ATS, like many organizations, submitted comments to improve and clarify the initial CMS proposal. Specifically, the ATS recommended extending the screening coverage to include Medicare beneficiaries aged 75-80, sought clarification on the shared decision making visits, recommended clarifying language on the term “asymptomatic” and noted the importance of a multidisciplinary team in diagnosing and managing lung cancer. The final CMS policy addresses these issues, with the age reaching 77, shared decision making clarified, and “asymptomatic” focused to symptoms related to lung cancer. Practitioners and programs should carefully review the final policy prior to establishing a site-specific screening protocol.

The CMS proposal is very detailed, mostly follows the National Lung Screening Trial (NLST) criteria, and requires specific personnel, shared decision making with the patient, specific documentation, smoking cessation counseling, detailed orders, specific radiology requirements, and participation in a registry. The specific CMS decision summary of the policy, copied directly from the website, is noted below1 for reference as there are extensive and very detailed requirements. Please review these carefully.

Private Insurance

Commercial carriers face a different issue. As most are aware, the USPSTF has recommended lung cancer screening for a broader age range.2 The grade of B was given for the validity of the supporting data. According to the Affordable Care Act, 3 all preventative services that received an A or B grade from the USPSTF must be covered by private insurance at no costs to the consumer.3 Commercial carriers are required incorporate category A and B recommendations with the plans annual renewal. It is important to note that the annual renewal date for private plans can happen through the calendar year. Private insurance coverage for lung cancers screening did not necessarily start in January for private patients. Providers should consult with patients and insurance companies to ensure lung cancer screening is covered.

Age and Coverage Policy

The coverage criteria are similar in all respects aside from age. This is not an issue in most situations as the 55-64 year old and the 65-77 year old with commercial insurance or Medicare should be covered. The most common scenario is of the younger patient with commercial insurance and the older group with Medicare. Interestingly, the 78-80 year old with Medicare is not covered unless they have commercial insurance as primary coverage. The commercially insured older patient is likely to represent a small group and CMS coverage is an issue if one is of the opinion that screening needs to be done in this age group.

Coding

Coding is multifactorial. However, there is no specific CPT code for the Evaluation and Management of a patient that presents for Lung Cancer Screening evaluation. Traditional outpatient consults (where applicable), new patient or established patient E & M coding should be used. The E & M selected must be commensurate with the level of service as determined by specific actions or counseling as one would with any visit. The diagnoses may include, but are not limited to: special screening for malignant neoplasm of the respiratory organs, V76.0 (ICD-9) or Z12.2 (ICD-10)4 and all diagnoses appropriate to the patient’s problems. Consider including a code for the tobacco history such as nicotine dependence (ICD-9 305.1, ICD-10 F17.200) or history of same (ICD-9 V15.82, ICD-10 Z87.891). The tobacco code is not specified but makes sense as these patients need a smoking history and pack years need to be documented in order to qualify for screening.

The radiologist will have a specific HCPCS code of S8032 Low-dose computed tomography for lung cancer screening.5 The above summary reflects the current point in time. Practitioners and programs are urged to carefully review the final policy before establishing program policies. Additionally, it is important to review the policies of individual commercial carriers as they often differ from CMS.

References

The following is copied directly from the CMS website1: *The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to add a lung cancer screening counseling and shared decision making visit, and for appropriate beneficiaries, annual screening for lung cancer with low dose computed tomography (LDCT), as an additional preventive service benefit under the Medicare program only if all of the following criteria are met:

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