Medicare Compliance & Reimbursement

Check criteria for determining most at-risk Medicare patients.

Good news: For the first time ever, you can now get Medicare reimbursement for lung cancer screening. But make sure you meet these criteria before submitting the claims.

On Feb. 5, the Centers for Medicare & Medicaid Services (CMS) announced the National Coverage Determination (NCD) to reimburse screening for lung cancer with low dose computed tomography (LDCT). Lung cancer is the third most common cancer and the leading cause of cancer deaths, according to CMS.

Why Coverage Decision Took So Long

With such prevalence and mortality related to lung cancer, you might be wondering why CMS has not provided screening coverage until now. Industry experts point to the lengthy, arduous processes for approving coverage.

Why? “Screening coverage decisions are dealt with very thoughtfully at CMS,” and require U.S. Preventive Services Task Force (USPSTF) consideration and rating, Medical Imaging & Technology Alliance (MITA) executive director Gail Rodriguez tells Medicare Compliance & Reimbursement Alert. “CMS is diligent in its process to determine whether a product or service is reasonable and necessary (the main criteria for coverage).”

For this NCD, CMS also consulted with a variety of stakeholders and considered a broad array of data, research and other factors in making its determination, Rodriguez says. “This process, while often long and frustrating, is a very serious business of weighing medical evidence against benefits, risks, and costs.”

The NCD comes about one year after the USPSTF solidified its recommendation for annual lung cancer screenings with LDCT, based on the National Lung Screening Trial (NLST) Protocol. The NLST found that patients who received screening were at a 15 to 20 percent lower risk of dying from lung cancer, according to the American Journal of Managed Care.

Impact: Many private payers already cover LDCT lung cancer screening, “but Medicare coverage is vital for those in the at-risk category,” Rodriguez notes. “It would make no sense for someone to have this coverage, then lose it once they turn 65.” Also, this coverage is estimated to save 20,000 lives per year, and “it should drive additional private insurance adoption.”

“With this decision, Medicare policy is now in line with current guidelines and the recommendations of many interested advocacy and professional organizations, including the Society,” American Cancer Society Chief Cancer Control Officer Richard Wender, MD said in a Feb. 6 statement. The Society “joined with several other professional societies, including the American College of Radiology, the American Thoracic Society, and the American College of Chest Physicians, to promote a quality framework that helped shape the CMS decision.”

Disadvantages: Another part of the delay in producing the NCD may involve the controversy over paying for lung cancer screening. For example, a December 2014 issue of the JAMA Internal Medicine discouraged CMS from paying for screening, pointing to radiation exposure, false positives and the qualifications of radiation centers. The Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) also voted against coverage of LDCT lung cancer screening back in April 2014.

Don’t Lose Out on Reimbursement — Meet These Criteria

Despite dissenters, Medicare will now cover lung cancer screening using LDCT once per year for beneficiaries who meet certain criteria. The NCD provides reimbursement for an office visit for counseling and shared decision-making on the benefits versus risks of lung cancer screening. 

The NCD is not, of course, without a myriad of criteria that you must meet to get reimbursement. Your Medicare patient must meet all of the following criteria:

• Age 55 to 77 years old;
• Asymptomatic (no signs or symptoms of lung cancer);
• Tobacco smoking history of at least 30 pack-years (one pack year equals smoking one pack per day for one year);
• Current smoker or one who has quit smoking within the last 15 years; and
• Receive a written order from a physician or qualified non-physician practitioner that meets certain requirements.

Make Sure the Visit Includes 5 Elements

The patient must have a lung cancer screening counseling and shared decision-making visit with a physician or a qualified non-physician practitioner (physician assistant, nurse practitioner or clinical nurse specialist). The healthcare provider must provide a written order for LDCT lung cancer screening during this visit, as well as document the visit in the patient’s medical record.

Planning: According to the NCD, the lung cancer screening counseling and shared decision-making visit must include:

1. Determination of 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;

2. Shared decision-making, including the use of one or more decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure;

3. Counseling on the importance of adherence to annual lung cancer LDCT screening, impact of comorbidities, and ability or willingness to undergo diagnosis and treatment; 

4. Counseling on the importance of maintaining cigarette smoking abstinence if a former smoker, or the importance of smoking cessation if a current smoker, and, if appropriate, providing information about tobacco cessation interventions; and

5. If appropriate, the furnishing of a written order for lung cancer screening with LDCT.

Include Essential Items in Written Orders

The beneficiary must also receive a written order for subsequent LDCT lung cancer screenings, but the healthcare provider can furnish these orders during any visit. Written orders for both initial and subsequent screenings must include:

• The beneficiary’s date of birth;
• Actual pack-year smoking history (number);
• Current smoking status (and for former smokers, the number of years since quitting);
• A statement that the beneficiary is asymptomatic;
• The ordering practitioner’s National Provider Identifier (NPI).

Heed Provider Eligibility Requirements, Too

For the LDCT lung cancer screening itself, CMS has a variety of eligibility criteria for both the radiology imaging facility and the reading radiologist. The eligible radiology imaging facility:

• Performs LDCT with volumetric CT dose index (CTDIvol) of ≤ 3.0 mGy (milligray) for standard size patients (defined as 5’ 7” and approximately 155 pounds) with appropriate reductions in CTDIvol for smaller patients and appropriate increases 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 (see “Submit This Data If You Want Reimbursement For LDCT Screening” on page 51).

Don’t overlook: Also, the reading radiologist must meet 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 three years;
• Documented participation in continuing medical education in accordance with current American College of Radiology standards; and
• Furnishes lung cancer screening with LDCT in a radiology imaging facility that meets the eligibility criteria above.

Resources: To read CMS’ Feb. 5 NCD announcement, go to www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-02-05.html. You can also access CMS’ decision memo on LDCT lung cancer screening at www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274.