CMS Manual System

1 CMS Manual System Department of Health & Human Services (DHHS) Pub 100-04 Medicare Claims Processing Centers for Medicare & Medicaid Services (CMS) Transmittal 3374 Date: October 15, 2015 Change Request 9246 NOTE: This Transmittal is no longer sensitive and is being re-communicated November 2, 2015. The Transmittal Number, date of Transmittal and all other information remains the same. This instruction may now be posted to the Internet. SUBJECT: Medicare Coverage of screening for Lung cancer with Low dose computed tomography (LDCT) I. SUMMARY OF CHANGES: The purpose of this Change Request (CR) is to inform contractors that Medicare covers lung cancer screening with low dose computed tomography (LDCT) if all eligibility requirements listed in the National Coverage Determination (NCD) are met. EFFECTIVE DATE: February 5, 2015 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: January 4, 2016 Disclaimer for Manual changes only: The revision date and transmittal number apply only to red italicized material.

2 Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents. II. CHANGES IN Manual INSTRUCTIONS: (N/A if Manual is not updated) R=REVISED, N=NEW, D=DELETED-Only One Per Row. R/N/D CHAPTER / SECTION / SUBSECTION / TITLE R 18/Table of Contents R 18 of Preventive and screening Services N 18/220/ screening for Lung cancer with Low dose computed tomography (LDCT) N 18 for Lung cancer with Low dose computed tomography (LDCT) N 18 Billing Requirements N 18 and Coinsurance N 18 Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages N 18 Working File (CWF) Edits III. FUNDING: For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract.

3 CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements. IV. ATTACHMENTS: Business Requirements Manual Instruction Attachment - Business Requirements Pub. 100-04 Transmittal: 3374 Date: October 15, 2015 Change Request: 9246 NOTE: This Transmittal is no longer sensitive and is being re-communicated November 2, 2015. The Transmittal Number, date of Transmittal and all other information remains the same.

4 This instruction may now be posted to the Internet. SUBJECT: Medicare Coverage of screening for Lung cancer with Low dose computed tomography (LDCT) EFFECTIVE DATE: February 5, 2015 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: January 4, 2016 I. GENERAL INFORMATION A. Background: Pursuant to 1861(ddd) of the Social Security Act, the Centers for Medicare and Medicaid Services (CMS) may add coverage of "additional preventive services" through the Medicare National Coverage Determinations (NCD) process. The additional preventive services must meet all of the following criteria: (1) reasonable and necessary for the prevention or early detection of illness or disability, (2) recommended with a grade of A or B by the United States Preventive Services Task Force (USPSTF), and, (3) appropriate for individuals entitled to benefits under Part A or enrolled under Part B. The CMS reviewed the evidence for lung cancer screening with low dose computed tomography (LDCT) and determined that the criteria listed above were met, enabling CMS to cover this additional preventive service under Medicare Part B.

5 Effective February 5, 2015, Medicare covers lung cancer screening with LDCT if all eligibility requirements listed in the NCD are met. B. Policy: Effective February 5, 2015, CMS has determined that the evidence is sufficient to add a lung cancer screening counseling and shared decision making visit, and for appropriate beneficiaries, annual screening for lung cancer with low dose computed tomography (LDCT), as an additional preventive service benefit under the Medicare program if all eligibility criteria described in the NCD are met. For purposes of Medicare coverage of lung cancer screening with LDCT, beneficiaries must meet all of the following eligibility criteria: Age 55 77 years; Asymptomatic (no signs or symptoms of lung cancer ); Tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes); Current smoker or one who has quit smoking within the last 15 years; and Receives a written order for lung cancer screening with LDCT that meets the requirements described in the NCD.

6 Written orders for lung cancer LDCT screenings must be appropriately documented in the beneficiary s medical records, and must contain the following information: Beneficiary date of birth; Actual pack year smoking history (number); Current smoking status, and for former smokers, the number of years since quitting smoking; Statement that the beneficiary is asymptomatic (no signs or symptoms of lung cancer ); and National Provider Identifier (NPI) of the ordering practitioner. Before the first lung cancer LDCT screening , the beneficiary must receive a lung cancer screening counseling and shared decision making visit, and if appropriate, receive the written order for his/her first lung cancer LDCT screen during such visit. Written orders for subsequent annual LDCT screens may be furnished during any appropriate visit with a physician or qualified non-physician practitioner (physician assistant, nurse practitioner, or clinical nurse specialist) as described in the NCD.

7 This NCD also establishes data collection requirements and specific coverage eligibility criteria for radiologists and radiology imaging facilities for purposes of Medicare coverage of lung cancer screening with LDCT. II. BUSINESS REQUIREMENTS TABLE "Shall" denotes a mandatory requirement, and "should" denotes an optional requirement. Number Requirement Responsibility A/B MAC DME MAC Shared- System Maintainers Other A B HHH FISS MCS VMS CWF 9246 - Effective for line-items on claims with dates of service on or after February 5, 2015, contractors shall recognize and add to systems new HCPCS codes 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), and G0297 - Low dose CT scan (LDCT) for lung cancer screening , as covered services. NOTE: HCPCS codes G0296 and G0297 are in the January 1, 2016 HCPCS and OPPS updates with an effective date of February 5, 2015, and in the January 2016 IOCE updates with an effective date of February 5, 2015.

8 HCPCS codes G0296 and G0297 are in the 2016 MPFSDB update which is effective for claims with 2016 dates of service. NOTE: Refer to Pub. 100-03, Medicare NCD Manual , chapter 1, section for coverage policy, and Pub. 100-04, Claims Processing Manual , Chapter 18, Section 220 for claims processing instructions. Type of Service (TOS) X X X X IOCE Number Requirement Responsibility A/B MAC DME MAC Shared- System Maintainers Other A B HHH FISS MCS VMS CWF G0296- TOS 1 G0297- TOS 1 9246 - Contractors shall not apply beneficiary coinsurance and deductibles to claim lines containing HCPCS codes G0296 or G0297. X X X IOCE 9246 - Contractors shall create a line-level edit to allow HCPCS code G0297 to be billed no more than once per annum. At least 11 full months must elapse from the date of the last screening . NOTE: This edit shall be overridable. X X 9246 - Contractors shall deny line-items on claims containing HCPCS code G0297 when reported more than once in a 12-month period (11 full months must elapse from the date of the last screening ) using the following messages: Claim Adjustment Reason Code (CARC) 119: Benefit maximum for this time period or occurrence has been reached.

9 Remittance Advice Remark Code (RARC) N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at If you do not have web access, you may contact the contractor to request a copy of the NCD. Medicare Summary Notice (MSN) : The following policy was used when we made this decision: NCD X X Number Requirement Responsibility A/B MAC DME MAC Shared- System Maintainers Other A B HHH FISS MCS VMS CWF Spanish Version Las siguientes pol ticas fueron utilizadas cuando se tom esta decisi n: NCD Group Code: CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file). NOTE: For modifier GZ, use CARC 50 and MSN 9246 - When denying line-items on claims per requirement , contractors shall use the following MSN message in addition to MSN , as well as the CARC/RARC listed in : MSN : Local Coverage Determinations (LCDs) help Medicare decide what is covered.

10 An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD . Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en ingl s) le ayudan a decidir a Medicare lo que est cubierto. Un LCD se us para su reclamaci n. Usted puede comparar su caso con la determinaci n y enviar informaci n de su m dico si piensa que puede cambiar nuestra decisi n. Para obtener una copia del LCD, llame al 1-800-MEDICARE (1-800-633-4227). NOTE: Due to System requirement, FISS has combined messages and so that, when used for the same line item, both messages will appear on the same MSN. X Number Requirement Responsibility A/B MAC DME MAC Shared- System Maintainers Other A B HHH FISS MCS VMS CWF 9246 - Contractors shall create an edit to allow HCPCS codes G0296 or G0297 to be billed only if the beneficiary is between the ages of 55-77.