Revised Medicare Guidelines for Lung Cancer Screening Using LDCT

CMS Announcement for Revised Coverage

The Centers for Medicare and Medicaid Services (CMS) has announced a shift in its eligibility criteria for coverage of lung cancer screening using low-dose CT (LDCT), with implementation date of October 3^rd, 2022. In addition, CMS also made other modifications to its eligibility criteria that will increase the ability of more people to obtain access to screening, effective February 10, 2022. The changes in National Coverage Determination (NCD) are as follows:

• CMS expanded patient eligibility for screening for lung cancer with low dose computed tomography (LDCT), including lowering the minimum age for screening
• CMS also removed the restriction that a physician or non-physician practitioner must provide the counseling and shared decision-making (SDM)
• CMS removed the requirement that facilities participate in a registry

Basics of Low Dose Computed Tomography (LDCT)

The only recommended screening test for lung cancer is LDCT. It’s a unique CT scan technique that combines special x-ray equipment with sophisticated computers to produce multiple, cross-sectional images or pictures of the inside of the body. CMS made the policy changes, effective February 10, 2022:

• Expanded patient eligibility for screening for lung cancer with LDCT to closely align with the U.S. Preventive Services Task Force recommendation
• Lowered the minimum age for screening from 55 to 50 years and reduced the smoking history from at least 30 pack-years to at least 20 pack-years
• Simplified the requirements for the counseling and SDM visit
• Removed the restriction that a physician or non-physician practitioner must provide the counseling and SDM
• Reduced the eligibility criteria for the reading radiologist
• Reduced the radiology imaging facility eligibility criteria (including removing the requirement that facilities participate in a registry).

With these changes, Medicare:

• Will allow you to bill codes G0296 and 71271 for patients between the ages of 50 and 77 for claims with a date of service on or after February 10, 2022
• Won’t search for and adjust LDCT claims with dates of service February 10, 2022 – October 3, 2022, but they’ll adjust such claims that you bring to their attention.

Beneficiary Eligibility Criteria

For purposes of Medicare coverage of lung cancer screening with LDCT, beneficiaries must meet all of the following eligibility 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 per day for one year; 1 pack = 20 cigarettes);
• Current smoker or one who has quit smoking within the last 15 years; and
• Receive a written order for lung cancer screening with LDCT. Written orders for lung cancer LDCT screenings must be appropriately documented in the beneficiary’s medical records, and must contain the following information:
  • Beneficiary date of birth;
  • Actual pack – year smoking history (number);
  • Current smoking status, and for former smokers, the number of years since quitting smoking;
  • Statement that the beneficiary is asymptomatic (no signs or symptoms of lung cancer); and
  • National Provider Identifier (NPI) of the ordering practitioner.

Reading Radiologist Eligibility Criteria

• For purposes of Medicare coverage of lung cancer screening with LDCT, the reading radiologist must meet all of the following eligibility criteria:
• Board certification or board eligibility with the American Board of Radiology or equivalent organization;
• Documented training in diagnostic radiology and radiation safety;
• Involvement in the supervision and interpretation of at least 300 chest computed tomography acquisitions in the past 3 years;
• Documented participation in continuing medical education in accordance with current American College of Radiology standards; and
• Furnish lung cancer screening with LDCT in a radiology imaging facility that meets the radiology imaging facility eligibility criteria.

Radiology Imaging Facility Eligibility Criteria

For purposes of Medicare coverage, lung cancer screening with LDCT must be furnished in a radiology imaging facility that meets all of the following eligibility criteria:

• Performs LDCT with volumetric CT dose index (CTDIvol) of ≤ 3.0 mGy (milligray) 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; and
• Collects and submits data to a CMS-approved registry for each LDCT lung cancer screening performed.

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References:

National Coverage Determination (NCD): Lung Cancer Screening with Low Dose Computed Tomography (LDCT)

MLN Document: Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)