The Highs and Lows of Lung Cancer Screening

All eligible patients should have access to lung cancer screening.lung cancer screening

Screening studies are among the most important services radiologists provide. Our ability to deliver these services requires scientific evidence that demonstrates improved outcomes.

But once the science matures, the next step is to ensure its financial viability. If physicians and facilities are not properly compensated for screening services, investment and expanded access will not occur.

The ACR Commission on Economics is committed to safeguarding compensation, but the path to reach this goal is often fraught with detours and roadblocks that must be overcome. In the December issue, I wrote about the ACR Commission on Economics' efforts to protect mammography services. In this month's column, I expand that discussion to include lung cancer screening.

The scientific literature supporting lung cancer screening utilizing low-dose CT (LDCT) has evolved for years, culminating in 2013 when the USPSTF recommended a grade B, justifying annual screening. A positive national coverage followed in early 2015, meaning Medicare would pay for the service. Despite these successes, challenges remain in 2017 relating to payment amounts and beneficiary access.

Payment

Payment for LDCT is reported by the following codes: G0296 (shared decision-making visit) and G0297 (the LDCT itself). However, payment for LDCT is too low for several reasons. The physician work (professional component, or PC) payment is the same payment amount as the diagnostic non-contrast chest CT (CPT code 71250). The value for 71250 is already inappropriately low due to CMS applying the single lowest Relative Value Scale Update Committee survey data point to determine its value in 2009. Moreover, this PC payment ignores the extra activities related to LDCT, including registry participation and the use of Lung-RADS™ in reporting. The practice expense (technical component) is also too low, particularly in the hospital outpatient setting, where services are paid through the Hospital Outpatient Prospective Payment System (HOPPS).

For 2017, CMS assigned LDCT to an ambulatory payment classification (APC) that pays around $60, despite ACR recommendations for a higher assignment. In fact, this payment is lower than the shared decision-making visit and the non-contrast chest. This assignment was based on only 40 billing claims made in 2015. This may relate to facilities holding claims for the first coverage year while waiting for CMS guidance on coding and claims submission.

What is the ACR doing to correct this payment shortfall? Much of our effort is focused on the HOPPS ambulatory payment category assignment, and we are encouraging facilities to properly report their costs (i.e., hospital cost reporting) for LDCT so future payment amounts do not suffer. Recall that the HOPPS is a prospective payment system, so costs reported this year will be applied in determining future payment. Proper reporting is a proactive step to take, and all our facilities can contribute. At the same time, we will stress to CMS HOPPS officials that clinical homogeneity across APCs is relevant, so increasing the APC assignment for LDCT is warranted.

Access

Many local Medicare Administrative Contactors (MACs) are challenging the ability to provide LDCT across all sites of service. They cite a regulation language from the late 1990s that includes the following language: "Effective for diagnostic procedures performed on or after March 15, 1999." As a result, select Medicare payers are indicating that payment for screening studies will not occur in Independent Diagnostic Testing Facilities (IDTFs) based on the following interpretation: "In accordance with this regulation, an IDTF, therefore, can only perform or provide diagnostic services. An LDCT is not a diagnostic test or service but a screening test and, therefore, in accordance with 42 CFR 410.33, it could not be performed in an IDTF." The ACR disagrees with this interpretation and has shared comments to reverse it. At press time, the ACR is still awaiting a decision regarding payment in the IDTF setting, and we will continue to pursue this issue until a favorable outcome is attained.


dr silvaBy Ezequiel Silva III, MD, FACR, Chair

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