What are the required diagnostic codes for Medicare and commercial insurance for lung cancer screening?

Required Diagnostic Codes for Medicare and Commercial Insurance for Lung Cancer Screening

For Medicare and commercial insurance coverage of lung cancer screening, specific diagnostic codes must be used based on patient eligibility criteria including age, smoking history, and absence of symptoms.

Medicare Coverage Requirements

• Medicare covers annual lung cancer screening with low-dose computed tomography (LDCT) for beneficiaries aged 55-77 years with a 30+ pack-year smoking history who currently smoke or have quit within the past 15 years 1
• Patients must have no signs or symptoms suggestive of lung cancer 1
• A shared decision-making visit conducted by a physician or qualified non-physician practitioner is required before the initial screening 1
• The use of decision aid(s) during this visit is mandatory to discuss benefits, harms, follow-up testing, and radiation exposure 1

Commercial Insurance Coverage Requirements

• Commercial insurers follow the US Preventive Services Task Force (USPSTF) guidelines, covering screening for individuals aged 55-80 years 1, 2
• Like Medicare, commercial insurance requires a 30+ pack-year smoking history and current smoking or having quit within the past 15 years 1
• No symptoms suggestive of lung cancer should be present 1
• Shared decision-making is recommended but not explicitly required for reimbursement 1

Provider and Facility Requirements

• For Medicare reimbursement, radiologists must have:

  • Current certification with American Board of Radiology (or equivalent) 1
  • Training in diagnostic radiology and radiation safety 1
  • Supervision and interpretation of >300 chest CT scans in the prior 3 years 1
  • Participation in continuing medical education as required by the American College of Radiology 1

• Screening facilities must be:

  • Accredited advanced diagnostic imaging centers with training and experience in LDCT screening 1
  • Using LDCT with <3.0 mGy for standard size patient 1
  • Using standardized reporting with criteria for lung nodule identification and classification 1
  • Submitting data on all LDCT screenings to a CMS-approved national registry 1

Coding Considerations

• The LDCT must be ordered during a lung cancer screening counseling and shared decision-making visit 1
• Screening LDCT exams are differentiated from diagnostic CTs by CPT code 1
• Smoking cessation counseling must be available and is recommended for current smokers 1

Important Caveats

• Lung cancer screening is not recommended for individuals with conditions that substantially limit life expectancy 1, 3
• Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that limits life expectancy or ability/willingness to undergo curative lung surgery 2
• Screening is not currently recommended for non-smoking individuals, regardless of other risk factors 4
• The American Cancer Society's 2023 updated guidelines recommend screening for individuals aged 50-80 with ≥20 pack-year smoking history, without the 15-year quit restriction 3

Following these coding and documentation requirements is essential to ensure proper reimbursement for lung cancer screening services while maintaining compliance with Medicare and commercial insurance policies.