Radiology Coding Alert

Make sure patients meet all required criteria to avoid any unnecessary denials.

Making sure you’ve got a proper handle on preventive measure screenings is important in the radiology specialty. Specifically, coders have to be fully aware of the broad array of criteria assigned to each particular service. These criteria can range from patient history and demographics to specifics surrounding the handling of order forms.

In terms of criteria, the Low Dose Computed Tomography (LDCT) scan is one of the more nuanced preventive exams in radiology. That’s why practices rely on coders to know exactly what criteria to look for to keep the process of preventive screenings such as LDCT streamlined and efficient.

Take a closer look at each of these important criteria so you can feel confident your LDCT submissions will never result in a denial.

Confirm Various Levels of Patient Eligibility

As you will see, reporting an LDCT using HCPCS code G0279 (Low dose CT scan (LDCT) for lung cancer screening) requires a cumulative effort on the part of the physician, the coder, and the referring provider. “Before billing out for an LDCT procedure, you’ve got to be aware of the broad range of necessary criteria the patient and provider must meet,” says Kimberly Berry CPC, RCC, auditing and education consultant at TrustHCS in Springfield, Missouri. “Among these criteria, you must account for eligibility with respect to the radiologist, the patient, and the imaging facility,” Berry advises.

According to Medicare, a patient must meet all five of the following demographic criteria in order to qualify for an LDCT cancer screening:

• Be age 55-77 years of age;
• Have no signs or symptoms of lung cancer;
• Have a 30-pack years or greater history of tobacco smoking;
• Be current smokers or have quit smoking within the last 15 years; and
• 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.

As for the final point regarding the written order, the following information must be included in the written order from the referring provider:

• Date of birth;
• Actual pack–year smoking history (number);
• Current smoking status, and for former smokers, the number of years since quitting smoking;
• A statement that the beneficiary is asymptomatic (no signs or symptoms of lung cancer); and,
• The National Provider Identifier (NPI) of the ordering practitioner.

Discern Between First, Subsequent LDCT Encounters

Next up, you should understand the differences in eligibility and criteria for patients receiving an LDCT screening for the first time, or a subsequent encounter. For first encounter patients, they must be referred during a counseling and shared decision-making visit by their primary care physician or another referring provider. For patients receiving a subsequent LDCT screening, a counseling and shared decision-making visit prior to the screening is not necessary. The patient simply needs to be referred by a physician or qualified nonphysician practitioner (NPP).

Remember: If the patient is a first-time LDCT screening candidate, the referring provider must attest, via the order, that a counseling and shared decision-making visit has taken place. For a full list of necessary criteria that makes up a counseling and shared decision-making visit, see: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/mm9246.pdf.

Note Differences Between Payer Policies

The above guidelines are specific to Medicare policies on LDCT screenings, but other payers may not necessarily follow the same rules. For example, Excellus BCBS will approve a patient for an LDCT cancer screening for the patient on an annual basis as long as the patient meets the criteria for a “high-risk” patient. “High-risk” patients, according to Excellus BCBS, are individuals “between age 55-80 years with 30 pack-year history of smoking cigarettes who are either:

• “A current smoker; or
• Have quit smoking within the past 15 years.”

Final note: “The CMS Regulations and Guidance direct contractors to issue payment only if ICD-10 code Z87.891 [Personal history of nicotine dependence] appears as the primary diagnosis,” advises Amanda Corney, MBA, medical billing operations manager for Medical Resources Management in Rochester, New York. “Additionally, you should report diagnoses indicating any current tobacco use, abuse, or dependence as well as any significant findings such as chronic obstructive pulmonary disease [COPD], pulmonary nodules, or neoplasms,” Corney relays.