Question CT Low dose Screening (71271)

raechelz

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If the eligibility requirements for the screening low dose lung cancer are not met are you coding the exam as diagnostic? If not what approach are you taking?
 

raechelz

Networker
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Thank you, I am questioning that if a patient doesn't meet the eligibility guidelines but has already been seen would you code it as a diagnostic CT chest? My thought process is on other screening exams coded as diagnostic it is because they are not asymptomatic and a diagnosis reason. This feels like it is insurance eligibility driven especially since the guidelines have changed to 20 packs and more for some but not CMS or our payers. If that makes sense?
 

rthomas@impcna.com

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I am wondering why the screening CT was ordered if the patient didn't qualify. Can you prove medical necessity if you end up coding as a diagnostic? Does the patient's insurance require precertification for a CT?
 

raechelz

Networker
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I am wondering why the screening CT was ordered if the patient didn't qualify. Can you prove medical necessity if you end up coding as a diagnostic? Does the patient's insurance require precertification for a CT?
Thank you for this! Bringing me back to the basics. Answer, no can't prove medical necessity as it is only because the patient doesn't meet CMS payer eligibility requirements. There is nothing coding wise that requires the payer elements. Authorization depends on the payer but more than likely yes. What sparked the question is the US preventative task force changed the pack years to over 20 instead of over 30. My centers took it upon themselves to make the changes to over 20 which left me without documentation of over 30 packs. CMS and payers have not updated their requirements. Thank you again.
 
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