The Centers for Medicare and Medicaid Services (CMS) issued a national coverage decision (NCD) on Feb. 5, 2015 announcing a new benefit for low dose computed tomography (LDCT) lung cancer screening for certain Medicare beneficiaries.

Although CMS has announced this huge life-saving benefit for the Medicare population as “effective immediately” in their press release, until further reimbursement instructions are released by CMS, the American College of Radiology (ACR) recommends that physicians meeting the coverage criteria hold all Medicare claims for LDCT lung cancer screening. Full details of the NCD can be found here.

Providers must meet all coverage criteria to be reimbursed by Medicare. The following frequently asked questions and answers, prepared by the ACR, address coverage and reimbursement requirements relating to patient eligibility, center eligibility, accreditation and lung cancer screening designation, radiologist requirements, clinical practice registry, and billing and payment.

For additional information on lung cancer screening coverage and reimbursement, visit the Lung Cancer Screening Resources page. For billing and payment questions, please email LCScoverage@acr.org.

Patient Eligibility

Which patients are covered by Medicare for LDCT lung cancer screening
?

Patients must:

  1. Be age 55-77 years of age
  2. Have no signs or symptoms of lung cancer
  3. Have a 30-pack years or greater history of tobacco smoking,
  4. Be current smokers or have quit smoking within the last 15 years, AND
  5. Have a written order for LDCT from a qualified health professional following a lung cancer screening counseling that attests to shared decision-making having taken place before their first screening CT
Is a written order and shared decision-making visit required for the initial and subsequent visits for LDCT lung cancer screening?

For the initial LDCT lung cancer screening service, a written order is required from a qualified health professional following a lung cancer screening counseling and with attestation to shared decision-making having taken place.

For the subsequent screening services, a written order is required which may be furnished during any appropriate visit from a qualified health professional.

What information is required to be included in the written order for the initial and subsequent visits for LDCT lung cancer screening?

For both the initial and subsequent lung cancer screening services, a written order is required to include:
  1. Beneficiary date of birth
  2. Actual number of pack years smoked
  3. Current smoking status, and for former smokers, the number of years since quitting smoking
  4. Statement that the beneficiary is asymptomatic (no signs or symptoms of lung cancer), AND
  5. National Provider Identifier (NPI) of the ordering practitioner

 

 Are there any example patient order forms available for lung cancer screening?

Are there any decision aid tools available for the shared decision making visit?

Yes, patient information for decision aids as well as smoking cessation materials are available here. A shared decision making aid with risk calculator is available at shouldiscreen.com.    

How do I bill for the shared decision-making visit?

The ACR defers to those specialty groups that perform the shared decision-making (SDM) visits and, therefore, the College recommends referencing The American Thoracic Society (ATS) coding recommendation published in its February Coding Newsletter. Existing evaluation and management consultative codes as well as specific diagnosis codes are included.

Center Eligibility

Which centers are eligible for LDCT lung cancer screening Medicare reimbursement?

Any center that:

  1. Uses LDCTs with volumetric CT dose index (CTDIvol) of ≤3.0 mGy for standard size patients (defined to be 5’ 7” and approximately 155 pounds) with appropriate reductions in CTDIvol for smaller patients and appropriate increases in CTDIvol for larger patients
  2. Utilizes a standardized lung nodule identification, classification and reporting system
  3. Makes available smoking cessation interventions for current smokers, AND
  4. Collects and submits specific data elements to a CMS-approved national registry for each LDCT lung cancer screening provided.
ACR Lung Cancer Screening Registry™

What is the status of the ACR’s Clinical Practice Registry for LDCT lung cancer screening?

The ACR Lung Cancer Screening Registry™, which is under development, was approved by the Centers for Medicare and Medicaid Services (CMS) to enable providers to meet quality reporting requirements to receive Medicare CT lung cancer screening payment.

Registry structure will be based on Lung-RADS™. Final data element specifications for the registry and measure definitions are provided below.

Anticipated Timeline:
  • Open for registration: May 2015  
  • Data submission: Summer 2015 (and data may be submitted retroactively on exams performed starting Jan. 1, 2015)
  • First feedback reports: Fall 2015
  • What radiology practices can do now?
  • Register each of your facilities that will be performing the lung cancer screening CT in our online New Facility Registration form
  • Complete and return a signed participation agreement to NRDR
  • Use the data dictionary available on the ACR website to start collecting data on all of the lung cancer screening CT exams that you are performing, not just CMS patients. The ACR LCSR requires data to be entered on all screened patients. When the registry interface is available, you will be able to enter all the collected data into the registry.
  • Talk to your electronic health record (EHR) vendor and your reporting vendors to ask if they can support data submission to the ACR Lung Cancer Screening Registry
What radiology practices can do now?
  • Register each of your facilities that will be performing the lung cancer screening CT in our online New Facility Registration form
  • Complete and return a signed participation agreement to NRDR
  • Use the data dictionary available on the ACR website to start collecting data on all of the lung cancer screening CT exams that you are performing, not just CMS patients. The ACR LCSR requires data to be entered on all screened patients. When the registry interface is available, you will be able to enter all the collected data into the registry.
  • Talk to your electronic health record (EHR) vendor and your reporting vendors to ask if they can support data submission to the ACR Lung Cancer Screening Registry
Where can I locate additional information regarding the ACR lung cancer screening registry?

More information on the ACR lung cancer screening registry is available at the ACR Lung Cancer Screening Registry webpage. Click here for the registry information letter.

Accreditation and Lung Cancer Screening Designation

Are centers required to be accredited and designated in lung cancer screening for LDCT lung cancer screening coverage?

Centers are not required to be accredited and designated in LDCT for lung cancer screening coverage. However, the ACR recommends centers use both in establishing best practice and a quality lung cancer screening program.

Background: CMS provided a response to commenters within the LDCT lung cancer screening final decision that removed the imaging facility criteria previously requiring either past participation in lung cancer screening trials or advanced diagnostic imaging accreditation with training and experience in LDCT lung cancer screening. In place of this criteria, CMS is requiring that imaging facilities use standardized lung nodule identification, classification, and reporting systems, and make available smoking cessation interventions for current smokers, based on the evidence reviewed. CMS believes these modifications strike an appropriate balance between maintaining appropriate and high quality access to these services, while reducing undue burden.

Does the ACR have a CT Accreditation for LDCT lung cancer screening and how long is the process in completing?

The ACR’s CT accreditation has approved status from CMS under the Medicare Improvements for Patients and Providers Act (MIPPA) and takes approximately four to six months from start to finish. The ACR Lung Cancer Screening Center program meets the CMS threshold for radiation dose per the final NCD. This is a rapid process and can be turned around quickly. Since this program was launched, the College continues to see enrollments increase. Over 900 facilities have qualified for an ACR Lung Cancer Screening designation since the program’s inception. For a comparison of the ACR Lung Cancer Screening Center Designation and ACR Lung Cancer Registry, learn more now.

Radiologist Requirements

What are the radiology physician requirements?

According to CMS’s proposed decision, radiologists must be:
  1. Board certified or board eligible with the American Board of Radiology or equivalent organization, with documented training in diagnostic radiology and radiation safety
  2. Have been involved with the supervision and interpretation of at least 300 chest CTs in the past three years
  3. Have documented CME per the ACR guidelines and parameters, AND
  4. Furnish LDCT lung cancer screening in a radiology imaging facility that meets the radiology imaging facility eligibility criteria specified in the CMS final coverage decision.
Billing and Payment

When can a center start billing Medicare for LDCT lung cancer screening?

Following the Feb. 5, 2015 national coverage decision, CMS may require a number of months to define and circulate coding and payment instructions to their local Medicare contractors. Although claims processing and payment may not be immediate, a CMS reimbursement policy is generally made retroactively to the date of the final coverage decision (Feb. 5, 2015). Claims should be held until CMS posts specific billing instructions for those centers that meet all coverage criteria. However, following the CMS instructions, we anticipate claims reimbursement will be made retroactively.

CMS generally posts these types of instructions in a Change Request Transmittal notice and also an MLN Matters article. The ACR will continue to closely monitor the CMS website for further instructions and will update readers through the Lung Cancer Resources page.

What is the appropriate CPT code for billing LDCT lung cancer screening?

The ACR has recommended that CMS implement a G code as the best coding structure for lung cancer screening coverage under Medicare and mirror the private payer S-code previously established in October 2014 (see ACR S-code article).

How much will Medicare and/or Managed Care pay for LDCT lung cancer screening and is there an additional reimbursement for the work tied to the data collection and submission to a CMS-approved registry?

The ACR recommends that the payment rate of CPT® code 71250 (Computed tomography, thorax; without contrast material) should serve as the reimbursement floor for LDCT lung cancer screening with additional RVUs assigned for the numerous quality criteria required of an effective lung cancer screening program and mandated in CMS’s final coverage decision. We anticipate more information on payment will be included in a future CMS notice/transmittal.

For additional details on private payer reimbursement, the ACR published an article including their recommendation for valuation of the lung cancer screening S-code. Although the ACR is explicit in their payment recommendation, private payer reimbursement rates may vary.

Do Medicare Advantage plans allow LDCT lung cancer screening coverage and payment? If so, how should this service be billed?

The ACR recommends that radiology groups and practices verify billing instruction for LDCT lung cancer screening with their individual Medicare Advantage plans to address the flexibility afforded to these plans by CMS.
Since the ACR’s recent lung cancer screening webinar, many practices have asked the College to clarify whether Medicare Advantage plans are required to await coding/billing instructions from CMS or if they are able to accept the S-code established in October 2014 for lung cancer screening (S8032 Low-dose computed tomography for lung cancer screening).

Medicare Advantage plans generally must provide coverage of all Medicare-covered services, but they are afforded flexibility in how and what they pay for those services. Based on past precedent, CMS is giving Medicare Advantage plans latitude with respect to coding and billing instructions for lung cancer screening. As such, the ACR is encouraging imaging practices to check with each of their Medicare Advantage plans to determine if the S-code is accepted or if they are awaiting instructions from CMS.

Lung Cancer Screening Resources


Additional ACR resources for lung cancer screening can be found on the ACR Lung Cancer Resources webpage. An ACR webinar on lung cancer screening can be viewed using this link to the presentation on YouTube.

Contact Us
Screening Center Designation
lungcancerscreening@acr.org
1-800-770-0145 x3712

Registry
nrdr@acr.org
1-800-227-5463 x3535

Coverage / Payments
LCScoverage@acr.org
1-800-227-5463 x4043

Education
info@acr.org
1-800-227-5463 x4040

If you have any questions, please contact Anita McGlothlin at amcglothlin@acr.org or email questions directly to LCScoverage@acr.org.