The Reading Room

Member asks: What's going on with lung cancer screening?

by Daniel Kuzmanovich

In the past year we’ve seen several developments around lung cancer screening.  We’ve profiled these changes in our blog posts on CMS’ lung cancer screening proposal and the  U.S. Preventive Services Task Force’s (USPSTF) “B” recommendation for lung cancer CT screening

Now, with CMS set to release the final decision memorandum next month, we’ve compiled a list of our membership’s most popular lung cancer screening questions regarding reimbursement, eligibility, data registries, and shared decision making, along with our answers.  

Reimbursement

I’ve heard that CMS is reimbursing for lung cancer screening for Medicare beneficiaries. Is that true?

If there aren’t any changes to the proposed decision memo, then yes, CMS will begin lung cancer screening reimbursement for Medicare beneficiaries in February 2015 (when it publishes the final decision memo).

What will CMS reimbursement for lung cancer screening look like?

There currently isn’t a CPT code specifically for lung cancer screening. However, in October CMS released an S code to be used when submitting these claims to private payers for reimbursement. The ACR is urging CMS to use CPT code 71250 (chest CT without contrast) as the floor for lung cancer screening reimbursement.

Are private payers reimbursing for lung cancer screening too?

The Affordable Care Act requires insurers to cover preventative services graded “B” or higher.  Since the USPSTF gave lung cancer CT screening a “B” recommendation, insurers are expected to cover it beginning this month.  Note that certain private plans may have been grandfathered out of this mandate.

For more on screening reimbursement and a list of insurers that currently already cover lung cancer screening, you can check out this lung cancer screening reimbursement primer.

Eligibility

Am I eligible for reimbursement as a lung cancer screening program?

It's unclear how restrictive CMS plans to be with lung cancer screening eligibility. The phrasing of the proposed decision memo eligibility requirement for reimbursement is "an accredited advanced diagnostic imaging center with training and experience in LDCT lung cancer screening." We’d like to think that ACR accreditation in CT would meet this requirement, but the wording provided in the proposed decision memo leaves room for interpretation.

When we last spoke with CMS we did not receive any further clarification about the screening eligibility requirements. Hopefully CMS will provide more guidance in their February ruling, at the urging of the ACR and other commenters.

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Data registries

The decision memo requires providers to collect and submit screening CT data to an approved registry for each screening. Which registries are approved?

The ACR’s National Radiology Data Registry (NRDR) is on CMS’ list of approved quality reporting registries. According to the proposed decision memo “national registries interested in seeking CMS approval must send a request either electronically or hard copy to CMS.” This means that other data registries may also qualify. You can review the full list of approved registries from CMS.

Shared decision making

What needs to happen before a patient is screened?

CMS’ proposed decision memo includes a requirement that, prior to a lung cancer screening procedure, a Medicare beneficiary must undergo a lung cancer screening counseling and shared decision making visit to “to include benefits, harms, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure.”

So, who should conduct the shared decision making visit- the primary care physician, or the screening program?

In our reading of the proposed decision memo it seems as though shared decision making can be conducted either at the primary care level or as part of the lung cancer screening program. Our research indicates that these shared decision making conversations tend to occur at the primary care level, though CMS leaves the possibility for them to occur as part of the lung cancer screening program as long as it’s conducted by a qualified clinician under section R of this social security act.

Will the shared decision making session be reimbursed?

It’s not clear whether Medicare will treat the shared decision making visit as a reimbursed event. The Lung Cancer Alliance (LCA) and others have submitted comments urging that CMS reimburse this event whether or not it leads to subsequent lung cancer screenings. Ideally we will have more clarification in February once the final decision memo is released. As things stand, shared decision making visits would not be reimbursed as a separate event from a regular clinician visit.

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