January 2016

In December, CMS issued the final payment rule for 2016 which included a new G-code (G0296) and clarification on how providers should document, code and bill for the shared decision making visit associated with the new Medicare lung cancer screening benefit.  While G G0296 – Counseling visit to discuss need for lung cancer screening using low dose CT (LDCT) scan (service is for eligibility determination and shared decision making) – was a welcome clarification of CMS policy, CMS immediately added confusion to the situation by issuing a document that limited ordering screening and providing the shared decision making visit to primary care physicians.

The ATS believes strongly that CMS policy to limit the service to only primary care providers is wrong.  The ATS believes pulmonary physicians should continue to provide the service to patients as medically necessary.

The confusion stems from a Medicare Learning Network Matter (MLN) article that states only primary care providers can order shared decision making visits and only primary care physicians can provide shared decision making visits.  The ATS believes strongly that the MLN article is wrong and that in fact pulmonary providers will be reimbursed by Medicare for ordering screening and providing shared decision making visits.

The MLN article is in essence an "educational" summary article of the Notice of Coverage Determination (NCD) document issued by CMS that states LDCT scans are a covered Medicare service and details the conditions of coverage.  The official CMS policy is contained in the NCD document.  There is nothing in the NCD document that expressly limits or implies limiting the service to primary care providers.  Further the U.S. Preventative Services Taskforce report on LDCT screening, which CMS based its NCD document on, does not limit the service to primary care providers, and in fact recognizes patients will be referred for screening from non-primary care providers. So the official policy documents on which CMS is basing its coverage policy for lung cancer screening do not limit the ordering of screening or the provision of shared decision making visits to primary care providers.

Further, the ATS has reached out to a number of directors of Medicare Administrative Contractors, the entities actually responsible for reviewing, processing and paying Medicare claims, and the MAC directors have reported that there are no plans to limit payment for this service to primary care physicians.  The MAC directors further note that, assuming proper coding and documentation, they plan to pay claims for the shared decision making visits from all physician providers (including specialists).

In summary, while the MLN article has created some confusion, the ATS believes the policy is clear; all physicians, regardless of specialty, are able to order lung cancer screening and provide the shared decision making visit. The ATS is actively advocating with CMS to resolve this situation.  Based on our contact with senior CMS staff, we expect to have further information in the near future.  We will share any information we receive with ATS members.  It is ATS's strong hope and expectation that CMS will clarify that all physicians are able to order lung cancer screening and provide the shared decision making visit.