HomeAboutNewsroomMember NewslettersCoding and Billing Quarterly2016February ▶ Pulmonary Physicians Can Order Lung Cancer Screening/Provide Shared Decision-Making Service
Pulmonary Physicians Can Order Lung Cancer Screening/Provide Shared Decision-Making Service

After compelling arguments by ATS and sister organizations, the Centers for Medicare and Medicaid Services Coverage and Analysis Group issued a clarification this week regarding which physicians can order lung cancer screening and provide the shared decision- making visit.

In its clarification statement, CMS states, “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.”

This clarification of its earlier statement is final assurance that pulmonary providers and other specialists can order lung cancer screening and provide the shared-decision making visit, provided all other CMS requirements are met.

The ATS is pleased that CMS has issued this clarification in a timely manner and the ATS believes this clarification puts to rest questions about which physicians and non-physician providers can order lung cancer screening and provide the shared decision making service.

The confusion stemmed from the publication of a recent Medicare Learning Network Matter (MLN) article that that states only primary care providers can order shared decision making visits and only primary care physicians can provide shared decision making visits. The MLN article is in essence an “educational” summary article of the Notice of Coverage Determination (NCD) document issued by CMS that states LDCT scans are a covered Medicare service and what the conditions of coverage are. The official CMS policy is contained in the NCD document. As the ATS pointed out in our communications to CMS that resulted in the clarification policy, there is nothing in the NCD document that expressly limits or implies limiting the service to primary care providers. Further the U.S. Preventative Services Taskforce report on LDCT screening, on which CMS based its NCD document, does not limit the service to primary care providers, and in fact recognizes patients will be referred for screening from nonprimary care providers.

Additionally, the ATS reached out to a number of directors of Medicare Administrative Contractors (MAC), the entities actually responsible for reviewing, processing and paying Medicare claims, and the MAC directors have reported that there are no plans to limit payment for this service to primary care physicians. The MAC directors further note that, assuming proper coding and documentation, they plan to pay claims for the shared decision making visits from all physician providers (including specialists).

In summary, while the MLN article has created some confusion and has not yet been retracted or corrected, the clarification policy provides ample guidance from CMS that all physicians are able to order lung cancer screening and provide the shared decision making service, provided all other CMS criteria are met.

LDCT Lung Cancer Screening - Important ICD-10-CM Coding Issue

And if the confusion surrounding what type of providers wasn’t enough, there is also a LDCT screening coding problem involving ICD-10-CM codes. Medicare will deny 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) and G0297 (Low dose CT scan (LDCT) for lung cancer screening) for claims that do not contain the ICD 9 CM code V15.82 (History of tobacco use) for claims with dates of service February 5, 2015 to September 30, 2015 and ICD-10-CM code Z87.891 (Personal history of nicotine dependence) for claims with dates of service on or after October 1, 2015. This leaves a gap for coding our patients that are current smokers. We have been in contact with CMS and understand they have plans to add ICD-10 code F17.2- (Nicotine dependence) in the future. However, for those patients who are current smokers, those claims will need to be held, as contractors do not currently have instructions and these claims will be denied.

How to Use the New LDCT Lung Cancer Screening Codes

The code to use for a SDM visit is G0296 (counseling visit to discuss need for lung cancer screening [LDCT]). This is a 15 minute code with reimbursement of $69.65 in the hospital out- patient setting and $28.64 in a physician’s office. It can be billed on the same day as an E/M visit, provided medical necessity is met. If this occurs, it should be billed with a 25 modifier added to the E/M service. The time to perform the E/M service is exclusive of the time to perform the SDM. Since this is a preventive service benefit, no patient copays are applicable. Remember to affix Z87.891 (Personal history of nicotine dependence) to the bill and hold the bill, if the patient is currently smoking (see above). Use code G0297 (Low dose CT scan [LDCT]) when the CT scan is ordered. Remember to add Z89.891 to the order sheet (see above). The reimbursement for G0297 is $112.49 in the hospital outpatient setting and $254.93 in a physician's office. For additional information on how to use the new codes for LDCT lung cancer screening appropriately, please visit the ATS website and listen to the webinar on eligibility, documentation and coding requirements for the new LDCT lung cancer screening benefit.

Last Reviewed: November 2016