UP Health System Marquette- a Designated Lung Cancer

Screening Center

Lung Cancer Screening with Low Dose CT for high risk patients and Tobacco Cessation, Promoting Prevention and Early Detection of Lung Cancer

National Lung Screening Trial

NLST was a randomized national trial involving 53,454 current and former heavy smokers ages 55-74

Participants were required to have at least 30 pack-years and were either a current smoker or former smoker within 15 years, without signs, symptoms or history of lung cancer.

NLST continued

Participants in the NLST were randomly assigned to receive three annual screens with either low-dose CT(LDCT) or chest X-ray(CXR)

On average over the three rounds of screening exams, 24.2% of the low-dose screening exams were positive and 6.9% of the chest X-rays were positive

NLST continued

Across all three rounds, when a positive screening was found, 96.4% of LDCT tests and 94.5% of the CXRs were false positive

Final results showed a 20% reduction in lung cancer mortality with LDCT vs CXR

NLST continued

Adenocarcinomas and squamous cell carcinomas were detected in early stages of disease in both arms of the trial, and more frequently with LDCT versus CXR

Small Cell Lung Cancers, which are more rapidly growing, were infrequently detected at early stages by LDCT or CXR

NLST continued

Radiation Exposure ◦ Low Dose CT scans used for screening deliver approximately 1/5 the radiation of a standard CT.

◦ This is the equivalent of 15 traditional Xray studies or 6 months of background environmental exposure

Additional Concerns

Continuing studies beyond 3 years ◦ Continued similar rates of cancer detection in years 2 and 3, although more recent studies have suggested the opposite

◦ LCDT should continue annually as long as patients meet parameters and are sufficiently healthy to derive benefit from early detection

Positive Screen Case Study Retired, 62 y/o active male presents for wellness

exam Physical Exam reveals normal lungs. Breathing is

unlabored rhonchi or rales, “even when walking through the woods or up hills or stairs”. No cyanosis, clubbing or edema

Negative for cough, sputum production, hemoptysis, or pleuritic discomfort

Weight stable Former smoker quit 5 years ago, 60 pack year

history Patient has prior history of occupational asbestos

exposure

Positive Screen Case Study cont.

Screening LDCT reveals RUL 2 cm nodule.

Diagnostic Workup includes a Pulmonary consult and bronchoscopy and PET CT. Bronchoscopic biopsy and washings were non-diagnostic, but the PET CT positive.

Positive Screen Case Study

Patient underwent IR guided biopsy which revealed adenocarcinoma

Patient underwent mediastinoscopy, thoracotomy and upper lobectomy

Final Diagnosis- Stage 1 non-small cell carcinoma, T1a, N0, M0

Follow up with primary care provider

Medicare Coverage of Lung Cancer Screening with Low Dose CT

Medicare Beneficiaries must meet all of the following criteria:

*Be 55-77 years of age;

*Be asymptomatic (no signs or symptoms of lung cancer);

*Have a tobacco smoking history of at least 30 pack years (1 pack year is 1pack x 1 year; 1 pack = 20 cigarettes

*Be a current smoker or one who has quit smoking within the last 15 years; and,

*Receive a written order for lung cancer screening with LDCT that meets the requirements described in the NCD.

Medicare Coverage of Lung Cancer Screening with Low Dose CT

Written Orders for Lung Cancer Screening must be appropriately documented in the beneficiary’s medical record, and must contain the following information:

*Date of birth;

*Actual pack-year smoking history (number);

*Current Smoking Status, and for former smokers, the number of years since quitting smoking;

*A statement that the beneficiary is asymptomatic (no signs or symptoms of lung cancer); and,

*The National Provider Identifier (NPI) of the ordering practitioner

Medicare Coverage of Lung Cancer Screening with Low Dose CT

Counseling and Shared Decision-Making Visit Before the first lung cancer low dose CT screening occurs, the beneficiary must receive a written order during a lung cancer screening counseling and shared decision-making visit that includes the following elements and is appropriately documented in the beneficiary’s medical records: *Must be furnished by a physician, qualified non-physician practitioner, PA, Nurse Practitioner, NP, or Clinical Nurse Specialist, CNS; and,

Medicare Coverage of Lung Cancer Screening with Low Dose CT

Counseling and Shared Decision-Making Visit

*Determination of beneficiary eligibility including age, absence of signs or symptoms of lung cancer, a specific calculation of cigarette smoking pack-years; and if a former smoker, the number of years since quitting;

*Shared decision-making, including the use of one or more decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure;

Medicare Coverage of Screening for Lung Cancer with Low Dose CT

Counseling and Shared Decision-Making Visit *Counseling on the importance of adherence to annual lung cancer screening, impact of co-morbidities, and ability or willingness to undergo diagnosis and treatment; *Counseling on the importance of maintaining cigarette smoking abstinence if former smoker; or the importance of smoking cessation if current smoker and; if appropriate furnishing of information about tobacco cessation interventions; and, *If appropriate, the furnishing of a written order for lung cancer screening using low dose CT

Medicare Coverage of Lung Cancer Screening with Low Dose CT

HCPCS Codes, Office PCP *G0296- Counseling visit to discuss need for lung cancer screening using low dose CT scan (service is for eligibility determination and shared decision-making)

AND

ICD-10 Code *Z87.891- Personal history of tobacco use/personal history of nicotine dependence

Must Bill Both Codes out Together

HCPCS Codes, Facility *G0297- Low Dose CT scan for lung cancer screening

Additional Concerns

Screening versus diagnostic studies ◦ “Screening” applies only to asymptomatic patients

with no other clinical suggestions of cancer

◦ Patients with respiratory symptoms and/or findings on exam or other studies should have an immediate and thorough diagnostic work up

◦ Screening may also be inappropriate for patients with significant co-morbidities who would not likely be able to undergo definitive lung cancer treatment or live long enough to derive benefit from it