Expanded Access to CT Lung Cancer Screening in Medicare

The ACR continues to work with Congress and CMS to ensure that Medicare preserves patient access to and proper reimbursement for CT lung cancer screening for patients at high risk of developing lung cancer.

Coverage/Reimbursement Challenges


MACs Deny Reimbursement for LDCT in an IDTF Setting

Since 2018, the American College of Radiology (ACR) and partner stakeholders have worked with the Centers for Medicare and Medicaid Services (CMS) urging them to affirm that Independent Diagnostic Testing Facilities (IDTFs) qualify for Medicare reimbursement covering low-dose computed tomography (LDCT) lung cancer screening.

More than 35 bipartisan members of the House of Representatives cosigned an October 1, 2018, letter to the Secretary of the Department of Health and Human Services and the Administrator of the Centers for Medicare and Medicaid Services (CMS) to express opposition to Medicare Administrative Contractors (MAC) that deny reimbursement for low-dose CT (LDCT) lung cancer screenings performed at Independent Diagnostic Testing Facilities (IDTFs). See more»

Status update: As of February 2021, MACs continue to deny claims billed in an IDTF setting for Medicare patients. CMS recommends reopening the NCD for lung cancer screening to resolve this issue. ACR concludes that the MACs are not correctly adhering to Medicare’s lung cancer screening NCD 210.14. We affirm LDCT lung cancer screening code G0297 is not an intervention/therapeutic service in the lung cancer screening NCD and urge CMS to publish a Change Request Transmittal notice instructing all MACs to cover this service. ACR will continue to engage Congressional champions and CMS to expand this life-saving screening benefit in all care settings including IDTFs.

MPFS/HOPPS


In Dec. 2020, the Centers for Medicare and Medicaid Services (CMS) released the 2021 Medicare Physician Fee Schedule (MPFS) and Hospital Outpatient Prospective Payment System (HOPPS) final rules. In these rules, CMS describes changes to payment provisions effective Jan. 1, 2021.

ACR staff has prepared a detailed analysis and comments on the final rule changes to the payment provisions.


MPFS
CMS is finalizing the values of 1.08 RVU for CPT code 71250, 1.16 RVU for CPT code 71260, 1.25 RVU for CPT code 71270, and 1.08 for CPT code 71271 as proposed. The values for CPT codes 71250, 71260, and 71270 are decreases from the current value. However, the value for 71271 is an increase from the previous value for G0297. The ACR strongly disagrees with the CMS rationale for adjusting the values throughout this family, as this disregards the survey data regarding the intensity of the services presented, as well as the recent 2016 survey data. The ACR is also disappointed that CMS maintained their refinements to the practice expense for CPT code 71271.

HOPPS
The ACR has raised concerns about the inadequate payments for CT lung screening based on flawed hospital data in past comment letters to CMS. The ACR has argued for more accurate APC placement of the CPT code 71271 (Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s)) into a higher APC to accurately reflect resources use and clinical similarity of procedures within APCs.

In 2021, CPT code 71271 is placed in APC 5521 (Level 1 Imaging without Contrast) with a payment rate of $80.90. Additionally, CMS has fully implemented the CT/MR cost center policy that the ACR has raised concerns about since its proposal in 2014. The ACR has raised concerns many times in the past regarding the use of claims from hospitals that continue to report under the “square foot” cost allocation method noting that it would underestimate the true costs of CT and MR studies. CMS has given the hospitals six years to adjust their cost allocation methods from “square foot” to either the “direct” or the “dollar” method. The implementation of the CT/MR cost center policy creates new challenges in maintaining accurate payment rates within the hospital outpatient setting.


USPSTF Lung Cancer Screening Guidelines


On July 7, 2021, U.S. Preventive Services Task Force (USPSTF) issued a draft recommendation statement on screening for Lung Cancer. Based on the evidence, the USPSTF recommends annual screening using a low-dose computed tomography (CT) scan for people aged 50 to 80 years old who are at high risk for lung cancer because of their smoking history. This is a B recommendation.

In this new draft recommendation, the Task Force has made two changes that will nearly double the number of people eligible for lung cancer screening. First, the Task Force now recommends that people start screening at age 50, rather than 55. Second, this recommendation reduces the pack-years of smoking history that make someone eligible for screening from 30 pack years to 20.

Recommendation Summary

Population

Recommendation

Grade 
Adults ages 50 to 80 years who have a 20 pack-year smoking history, currently smoke, or have quit within the past 15 years The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults ages 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. B

 

By expanding who is eligible for screening, the changes to this recommendation will be especially helpful to African Americans and women. Data show that African Americans and women tend to smoke fewer cigarettes than white men. Data also show that African Americans have a higher risk of lung cancer than white people. These changes will mean that many more African American and female smokers will be eligible for this potentially life-saving screening.

About USPSTF

The USPSTF is an independent, volunteer panel of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications.

The ACR strongly supports the USPSTF proposal to lower the starting age for screening from 55 to 50 and the smoking history requirements from 30 pack-years to 20 pack-years. To facilitate additional expansion of access to this lifesaving screening, the ACR is encouraging the USPSTF to further broaden screening eligibility requirements to include critical metrics designed to enhance opportunities for minorities and women, such as removing the 15-year smoking cessation quit date.

For Medicare beneficiaries, coverage and reimbursement considerations will be handled by the Centers for Medicare and Medicaid Services Coverage and Analysis Group. Based on the updated recommendation statement, it is likely the 2015 National Coverage Determination  for lung cancer screening with LCDT will require updates.

The USPSTF final recommendation was released March 9, 2021. Download the full recommendation statement.

Resources


Lung Cancer Screening in 2017 HOPPS


Lung Cancer Screening Resources

LCSResources_320

The ACR is your best resource for safe, effective lung cancer screening with the latest research, toolkits and key patient information.

Access Now

RAN

RAN_320

Join members across the country who are ensuring that radiology's voice is heard at the local and federal levels.

Get involved today