CMS Pub. 100-04, ch. 18, § 220.2

Effective for claims with dates of service on and after February 5, 2015, providers may use the following

types of bill (TOBs) when submitting claims for LDCT lung cancer screening, HCPCS codes G0296 and

G0297: 12X, 13X, 22X, 23X, and 85X.

Effective for claims with dates of service on and after February 5, 2015, providers may also use the following

TOBs when submitting claims for LDCT lung cancer screening, HCPCS code G0296: 71X, 77X, and 85X

with revenue code 096X, 097X, and 098X.

The service shall be paid on the basis shown below:

• Outpatient hospital departments - TOBs 12X and 13X - based on Outpatient Prospective Payment

System (OPPS),

• Skilled nursing facilities (SNFs) - TOBs 22X and 23X - based on the Medicare Physician Fee

Schedule (MPFS),

• -Critical Access Hospitals (CAHs) - TOB 85X - based on reasonable cost,

• -CAH Method II - TOB 85X with revenue code 096X, 097X, or 098X based on the lesser of the actual

charge or the MPFS (115% of the lesser of the fee schedule amount and submitted charge) for HCPCS

code G0296 only,

• -Rural Health Clinics (RHCs) - TOB 71X - based on the all-inclusive rate for HCPCS G0296 only, and

• -Federally Qualified Health Centers (FQHCs) - TOB 77X - based on the prospective payment systems

(PPS) rate for HCPCS G0296 only.

NOTE: For outpatient hospital settings, as in any other setting, services covered under this NCD must be

ordered and performed by eligible Medicare providers for these services that meet the eligibility and coverage

requirements of this NCD. See Pub.100-03, Medicare NCD Manual, Chapter 1, Section 210.14, for complete

coverage requirements.