Low-Dose CT Lung Cancer Screening FAQ

As of March 9, 2021, the USPSTF recommends adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years:

• Screen for lung cancer with low-dose computed tomography (CT) every year.
  
• Stop screening once a person has not smoked for 15 years or has a health problem that limits life expectancy or the ability to have lung surgery

Grade: B

Download the full recommendation statement

1. Assess risk based on age and pack-year smoking history: Is the person aged 50 to 80 years and have they accumulated 20 pack-years or more of smoking?
1. A pack-year is a way of calculating how much a person has smoked in their lifetime. One pack-year is the equivalent of smoking an average of 20 cigarettes—1 pack—per day for a year.
2. Screen: If the person is aged 50 to 80 years and has a 20 pack-year or more smoking history, engage in shared decision making about screening.
   1. The decision to undertake screening should involve a discussion of its potential benefits, limitations, and harms.
   2. If a person decides to be screened, refer them for lung cancer screening with low-dose CT, ideally to a center with experience and expertise in lung cancer screening.
   3. If the person currently smokes, they should receive smoking cessation interventions.

How often?

• Screen every year with low-dose CT.
• Stop screening once a person has not smoked for 15 years or has a health problem that limits life expectancy or the ability to have lung surgery.

Patients must meet the following five criteria:

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
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

No. There are no randomized trials based on these risk factors. It is possible that future recommendations could include other risk factors or individual patient risk assessment.

CMS specifies “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.”

The USPSTF specifies “A “pack-year” means that someone has smoked an average of one pack of cigarettes per day for a year. For example, a person who has smoked a pack a day for 30 years has a 30 pack-year history of smoking, as does a person who smoked two packs a day for 15 years.”

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.

For both the initial and subsequent lung cancer screening services, a written order is required to include all of the following information:

1. Beneficiary date of birth
2. Number of pack-years smoked
3. Current smoking status, or for former smokers, the number of years since quitting smoking
4. Statement that the beneficiary is asymptomatic (no signs or symptoms of lung cancer)
5. National Provider Identifier (NPI) of the ordering practitioner

• Sample patient order forms

Medicare contractors are accepting claims for the shared decision-making visit retroactive to the date of the national coverage determination (Feb. 5, 2015). (Change Request Request Transmittal 185 and Transmittal 3374)

The following G code should be used for the shared decision-making visit:

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)

As long as the NCD requirement for the counseling and shared decision-making visit are met, the counseling visit may be billed on the same day as a medically necessary E/M visit or an annual wellness visit with the -25 modifier. The shared decision-making visit is not subject to coinsurance or deductibles. More details regarding this topic is addressed in the ACR 2016 MPFS comment letter to CMS.

Before the beneficiary’s first lung cancer LDCT screening, the beneficiary must receive a counseling and shared decision-making visit that meets all of the following criteria, and is appropriately documented in the beneficiary’s medical records:

• Must be furnished by a physician (as defined in Section 1861(r)(1) of the Social Security Act) or qualified non-physician practitioner (physician assistant, nurse practitioner, or clinical nurse specialist as defined in §1861(aa)(5) of the Social Security Act).

Per CMS,“the National Coverage Determination (NCD) for Lung Cancer Screening with LDCT (210.14) is based on the recommendation of the United States Preventive Services Task Force (USPSTF) whose general focus is the primary care provider and setting. We recognize the NCD does not specifically state primary care physician or setting. Based on the NCD and applicable regulations, the physician or non-physician practitioner who furnishes the shared-decision making visit and orders the LDCT must be treating the beneficiary and use the results in the management of the beneficiary's specific medical problem to ensure improved health outcomes.”

The ACR agrees with the NCD language that specifies that a physician or qualified non-physician practitioner must perform the shared decision-making visit. As defined in §1861(r) of the Social Security Act (the Act), a “treating physician” is a physician, who furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results of a diagnostic test in the management of the beneficiary’s specific medical problem.

The ACR recommended a revision or clarification be included in their MLN Matters article that currently states “NOTE: For outpatient hospital settings, as in any other setting, services covered under this NCD must be ordered by a primary care provider within the context of a primary care setting and performed by an eligible Medicare provider for these services.”, as this language may have unintended consequences and result in potential confusion.

Any center that the meets all of the following criteria is eligible:

• 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
• Utilizes a standardized lung nodule identification, classification and reporting system
• Makes available smoking cessation interventions for current smokers
• Collects and submits specific data elements to a CMS-approved national registry for each LDCT lung cancer screening provided

The ACR Lung Cancer Screening Registry™, 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.

No. However, the ACR recommends centers use both in establishing best practices 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 these 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.

The ACR 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.

Over 900 facilities have qualified for an ACR Lung Cancer Screening designation since the program’s inception.

According to CMS’s proposed decision, radiologists must meet all of the following criteria:

• Board-certified or board-eligible with the American Board of Radiology or equivalent organization, with documented training in diagnostic radiology and radiation safety
• Have been involved with the supervision and interpretation of at least 300 chest CTs in the past three years
• Have documented CME per the ACR guidelines and parameters
• 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

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.

CY 2021 Medicare Physician Fee Schedule Codes and Payment Levels for LDCT Screening*

*These totals have been calculated by multiplying the total Relative Value Units for each code and multiplying them by the CY 2021 MPFS conversion factor ($34.89).

CY 2021 Hospital Outpatient Prospective Payment System (HOPPS) Codes and Payment Levels for LDCT Screening**

**These rates are calculated by multiplying the relative weight of the Ambulatory Payment Classification (APC) groupings of the two codes by the CY 2021 HOPPS conversion factor ($82.797).

The ACR recommends that radiology groups and practices verify billing instructions for LDCT lung cancer screening with their individual Medicare Advantage plans to address the flexibility afforded to these plans by CMS.

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-RADS category 1 and 2 are negative screenings and the 12-month LDCT is the next annual screening CT. An LDCT annual screening exam should be reported as the next management step for Lung-RADS category 1 and 2. However, interim CTs are considered diagnostic and should use diagnostic non-contrast chest CT code.

An example of report text for the results impression:

Lung-RADS category 1: Negative screen. Recommend continued annual low dose CT screening in 12 months. Lung-RADS category 2: Negative screen. Recommend continued annual low dose CT screening in 12 months.

No. However, a best practice for screening programs is to track patients with Lung-RADs 3 and 4, and if they have not come back to their practice, to remind the referring physician and/or patient.

For example, a monthly data pull of all patients with Lung-RADs 3 and 4, and verification of schedule for a follow-up test or appointment, and tracking the patients to ensure and encourage adherence; if they are not scheduled by the time window recommended in Lung-RADs, inform and alert the referring provider.

For Lung-RADS categories 1 and 2 with recommendations at a 12 month cycle, are considered an annual screening exam and reported with CPT code 71271.

For Lung-RADS categories 3 and 4 with recommendations at 3-6 month follow up, CPT code 71250 non-contrast chest CT (diagnostic) is reported.

• Medicare Contractors shall end date expired HCPCS G0297 effective December 31, 2020.
• Medicare Contractors shall add CPT 71271 replacement effective January 1, 2021.

Reference: CMS Transmittal 10624

The thorax CT codes 71250, 71260, and 71270 have been revised editorially as diagnostic studies to distinguish them from thorax screening CT (71271).

For more information refer to the Sept/Oct 2020 ACR Coding Source regarding the 2021 CPT code update. It can also be found in the AMA Fall 2020 Bulletin of Clinical Examples in Radiology. (Log-in credentials are required.)

The ACR recommends the following per the ACR Lung Cancer Screening Center Designation:

Recommended Screening Population

• Majority of patients screened are between the ages of 55 and 80
• Have a smoking history of 30 pack years
• If no longer smoking, stopped smoking in 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.
• Persons who have undergone chest CT within 12 months should be excluded (initial screening)