Radiology Coding Alert

Don’t forget to assign counseling codes.

Radiologists perform low-dose computed tomography (LDCT) scans to evaluate eligible patients for possible lung cancer. While the LDCT screening is reported with 71271 (Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s)), coders can easily overlook other aspects of the scanning procedure when reporting the exam that could leave claims in the denial pile.

Radiology Coding Alert pulled together three common LDCT coding mistakes in order to show you how to correct them.

Mistake 1: Missing applicable counseling codes.

One common mistake with LDCT coding is failing to include any counseling codes. The screening exam requires a counseling visit and, if the patient is a current smoker, this means smoking cessation counseling, as well.

Consequently, before the provider can perform the LDCT screening test, the provider must counsel the patient on the procedure. You’ll report this portion of the visit with 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)).

In this particular encounter, the physician counsels the patient on the procedure and discusses shared decision making regarding the procedure during the counseling visit. The following topics are covered:

• Physician determines the patient’s eligibility for the LDCT screening;
• Shared decision-making discussion with one or more decision aids;
• Discuss the importance of annual LDCT screenings, possible effects on the patient’s comorbidities, and the patient’s cooperation to undergo diagnostic testing and treatment; and
• Counseling on quitting smoking if the patient is currently a smoker or continuing to abstain from cigarette smoking if the patient is a former smoker.

Telehealth LDCT counseling: According to CMS’s 2023 Medicare Physician Fee Schedule (MPFS) final rule, G0296 can be furnished via telehealth. Simultaneously, the service can be provided as an audio-only interaction, also known as a phone call. If the counseling visit is furnished as an audio-video telehealth visit, you’ll append modifier 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system), but you’ll append modifier 93 (Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system) if the counseling visit is furnished via audio-only means.

You might also receive medical reports that show the counseling visit and the LDCT exam occurred on the same day. In a National Coverage Analysis (NCA), the Centers for Medicare & Medicaid Services (CMS) issued a final decision memo in 2022 that indicates the counseling visit and LDCT exam may occur on the same day. “As long as the counseling and shared decision-making visit occurs before the beneficiary’s first lung cancer screening exam then it satisfies the [National Coverage Determination (NCD)],” the agency wrote (>www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=304).

Smoking cessation counseling: If the physician provides smoking cessation counseling to the patient in addition to the shared decision-making visit, you’ll assign one of the following codes depending on the time spent counseling the patient:

• 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes)
• 99407 (… intensive, greater than 10 minutes)

CMS encourages providers to continue to offer smoking cessation counseling to patients who are current smokers, but it does not require the service for LDCT screenings. “While smoking cessation services are appropriate for patients, we are not making it a requirement that imaging facilities furnish the service because it would prevent [independent diagnostic testing facilities] from furnishing LDCT screening,” CMS wrote in its decision memo.

Mistake 2: Missing diagnosis codes.

As with every claim, showing medical necessity for the encounter, service, or procedure is a must to receive reimbursement for the provider’s services. A common mistake with LDCT lung cancer screenings is failing to provide any or the correct diagnosis codes for the procedure.

Typically, the screening applies to patients with a history of or dependence on cigarettes. In those cases, you’ll assign any of the following ICD-10-CM codes:

• Z87.891 (Personal history of nicotine dependence)
• F17.211 (Nicotine dependence, cigarettes, in remission)
• F17.213 (… with withdrawal)
• F17.218 (… with other nicotine-induced disorders)
• F17.219 (… with unspecified nicotine-induced disorders)

Additionally, if the radiologist documents an abnormality on the screening that could require further testing, you’ll need to assign an applicable code like R91.8 (Other nonspecific abnormal finding of lung field). This code includes “Lung mass NOS found on diagnostic imaging of lung” as a synonym.

Mistake 3: Not checking patient eligibility.

Annual LDCT screenings are important for checking certain patients for lung cancer before the disease can develop. However, not every patient is eligible for the exam.

Patients who meet certain criteria are eligible for the annual lung cancer screening. According to NCD 210.14, a patient is eligible for an LDCT scan if the beneficiary:

• Is 50-77 years old;
• Is not exhibiting signs or symptoms of lung cancer;
• Has a tobacco smoking history of at least 20 pack-years;
• Is a current smoker or has quit within the last 15 years; and
• Received an LDCT lung cancer screening order.

(Resource: www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=364)

In February 2022, the NCD lowered the minimum age for the LDCT exam from 55 to 50 years old, and the pack-years were reduced from 30 to 20. Pack-years is a number that explains a patient’s extended smoking habit, and the number is determined by multiplying the daily pack consumption by the duration in years.

Despite establishing the eligibility requirements listed above, CMS indicates that a written order isn’t required in its final decision memo. The agency wrote “eliminating the excessive requirement for a written order will reduce administrative burden and facilitate improved access to lung cancer screening with LDCT.”

However, make sure you check with your individual payers for their LDCT lung cancer screening eligibility requirements. CMS may not require a written order for the scan, but commercial payers may, and having the documentation will help back up your claim in the event of a denial.