Understanding and Following Insurance Requirements and Mandates

The insurance landscape for LCS is complex. The Affordable Care Act mandates all private insurers must provide no co-pay coverage for all USPSTF Grade A and B recommendations, including LCS for the USPSTF defined high-risk population. Unfortunately, the CMS and USPSTF high-risk groups are slightly different, often leading to confusion when determining patient eligibility. Further complicating the matter are society recommendations which expand the high-risk group beyond the USPSTF and CMS eligibility criteria. These issues and others are addressed by the responses below.

AM/SR: An overview of insurance requirements for Group 1 and Group 2 criteria is summarized in this table.

Requirements for CT Lung Cancer Screening


CCT: It is important to understand each of these requirements by insurance provider to ensure reimbursement. Required elements for documenting eligibility are hard coded into the LCS exam order within the EHR. These criteria are verified at the time of imaging by the radiology center using standardized forms.


GM/CCT: Specific requirements were outlined by Medicare and documented in a summary written by Carly Carlson in March 2016.18

Below is a practical summary of the rules for performing and billing for these screening services.

Codes and Payment Levels* for LDCT Screening

Description
Code
Professional component
Global payment
Counseling visit to discuss need for screening with LDCT
G0296
$28.64
$28.64
LDCT scan for LCS
G0297
$51.56
$254.93

*Fees used for illustration are from the national Medicare fee schedule, using the 2016 conversion factor. Medicare applies a geographic adjustment to develop actual fees paid in each area of the country.

Summary of LDCT LCS Reimbursement Provisions in CY 2018 HOPPS Final Rule.19

Click to View Table:

Codes and Payment Levels* for LDCT Screening

GM: LCS coverage varies widely depending on the plan. The most common plans are outlined in the accompanying table including criteria for coverage, cost-sharing i.e., fees paid by the plan member as well as additional costs such as physician or facility fees. It is recommended to contact the insurer directly for coverage questions in advance of providing LCS services and obtain a pre-authorization to ensure reimbursement.

Insurance Plan
Eligibility Criteria
Cost Sharing
Additional Costs
Additional Information
Employer-Sponsored Plan
Age 55-80
30 pack-year smoking Current smoker or quit within 15 years
No co-pay, co-insurance or deductible
*May be additional costs associated with screening (e.g. facility fees)
*If plan grand-fathered under Affordable Care Act then coverage not required.
Medicare
Ages 55-77
30 pack-year smoking Current smoker or quit within 15 years
No signs or symptoms of lung cancer
No co-pay, co-insurance or deductible
*May be additional costs associated with screening (e.g. facility fees)
 
Medicare Advantage Plan
Ages 55-77
30 pack-year smoking
Current smoker or quit within 15 years
No signs or symptoms of lung cancer
*May charge co-pay, coinsurance or deductible if out-of-network
No additional costs associated with screening
*May cover beyond age 77 depending on plan.
State Health Insurance Marketplace Plan
Age 55-80
30 pack-year smoking
Current smoker or quit within 15 years
No co-pay, co-insurance or deductible
May be additional costs associated with screening (e.g. facility fees)
 
Medicaid
*Criteria varies by state.
*May charge co-pay, coinsurance or deductible
*May be additional costs associated with screening (e.g. facility fees)
*Coverage varies by state (see Medicaid.gov)
May be pre-determined facility or providers.
Individual Private Plan
Age 55-80
30 pack-year smoking
Current smoker or quit within 15 years
No co-pay, co-insurance or deductible
*May be additional costs associated with screening (e.g. facility fees)
*If plan grand-fathered under Affordable Care Act then coverage not required.
TRICARE
Age 55-80
30 pack-year smoking
Current smoker or quit within 15 years
No co-pay, co-insurance or deductible
No additional costs associated with screening
 

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Insurance Plan Comparison

ABK/CCT: The shared decision-making visit has a separate Healthcare Common Procedure Coding System (HCPCS) billing code that can be generated in the face- to-face visit and is distinct from the CT scan, which is billed through radiology.33,34 The two codes are listed below. At least 11 elapsed months must pass between screenings (billing for G0297). Medicare coinsurance and Part B deductible are waived for this service.33,34

  • G0296 – LDCT-LCS Shared Decision-making session.

    • Counseling visit to discuss need for lung cancer screening (LDCT) using low-dose CT scan (service is for eligibility determination and shared decision making).
    • APC 582.
  • G0297 – Low-dose CT (LDCT) scan for lung cancer screening.

    • APC 552.

Services must be billed with ICD-10 diagnosis codes:

  • Z87.891 for former smokers (personal history of nicotine dependence).
  • F17.2 for current smokers (nicotine dependence).