Lung cancer continues to be one of the leading causes of death from cancer across the world. Detection is early, and LDCT has set the game changer in recognizing lung cancer in its earliest, most treatable stages. However, before receiving LDCT screening, a counseling and shared decision making visit, which is billed under the g0296 CPT Code/HCPCS, is reimbursable for Medicare and most insurers.
We’ll discuss all that you need to know about the code, eligibility, documentation, reimbursement, best practices, and frequently asked questions.
What is G0296 CPT Code? Understanding the Code
G0296 is a code from the HCPCS set for:
“Counseling visit to discuss the need for lung cancer screening using low dose CT scan (LDCT) (service is for counseling and shared decision making before the first screening LDCT is performed).”
This code is crucial to providers who want to be compliant with the requirements of Medicare and other payers regarding lung cancer screening.
Why is G0296 Important?
- Ensures Patient Understanding: Patients have to be aware of all possible advantages, drawbacks and limitations related to LDCT screening.
- Meets Medicare Requirements: Medicare will require this counseling visit before the first LDCT screening.
- Optimizes Reimbursement: Correct utilization of G0296 ensures that shared decision-making does not cost providers a penny, since they will be reimbursed for both time and skill.
- Improves Outcomes: Educated patients are more likely to follow screening and follow-up recommendations.
Who Can Bill G0296?
- Physicians
- Non-Physician Practitioners (NPPs): These include Nurse Practitioners (NPs), Physician Assistants (PAs), and Clinical Nurse Specialists (CNSs).
- Auxiliary Personnel: Auxiliary staff can do the SDM in compliance with the “incident to” billing provision whilst supervised by a physician or an NPP.
Eligibility Criteria for G0296
As per the 2022 CMS updates, beneficiaries must meet the following criteria:
- Age: 50–77 years
- Smoking History: At least 20 pack-years.
- Smoking Status: Current smoker or quit within the past 15 years.
- Health Status: Asymptomatic for lung cancer.
- Counseling Session: Undergo a face-to-face or telehealth SDM visit using a decision aid.
Documentation Requirements
Compliance and reimbursement of reimbursement require accurate documentation.
- Patient Demographics: Age, smoking history, and current smoking.
- Counseling Details: Review of LDCT benefits and risks, such as false positives, radiation exposure, and overdiagnosis.
- Decision Aid Usage: Receipt of a CMS-approved decision aid at the SDM visit.
- Smoking Cessation: Counseling given and resources extended to current smokers.
- Written Order: For LDCT screening, the inclusion of the ordering practitioner’s National Provider Identifier (NPI).
Reimbursement and Coverage for CPT Code G0296
CPT code G0296 is central to Medicare’s preventive services for early detection of lung cancer through counseling and shared decision making (SDM). Compliance and accurate billing are facilitated by knowledge of the reimbursement and coverage nuances.
Reimbursement Rates
Payment for G0296 is contingent on location.
- Physician's Office (Non-Facility Setting): Approximately $29.07.
- Hospital Outpatient Setting (Facility Setting): Approximately $69.65.
Billing Considerations
- Frequency: G0296 is billable once per beneficiary before the first LDCT screening.
- Modifiers: If performed on the same day as an Evaluation and Management (E/M) service, append modifier -25 to the E/M code.
- Place of Service (POS):
- 11: Office.
- 22: Outpatient hospital.
- 10: Telehealth provided in the patient’s home.
- Telehealth: G0296 is approved for telehealth, including audio-only visits.
Institutional Billing
For institutional claims, G0296 is payable under the following Type of Bill (TOB) codes:
- 12X and 13X: Hospital outpatient departments.
- 22X and 23X: Skilled nursing facilities.
- 71X and 77X: Rural health clinics and federally qualified health centers.
- 85X: Critical access hospitals.
Compliance and Best Practices for G0296 Billing
- Training: Training all employees routinely on the most recent CMS and payer guidelines for preventive and telehealth services are legal to avoid wrongly coding and documenting156.
- EHR Integration: Use of electronic health records to automate eligibility, document what is required, and capture decision aids and counseling components for every G0296 visit.
- Audit Preparedness: Keep record of eligibility, counseling content, and shared decision making discussions in a creative and orderly way to support claims and stand a chance in the face of audit1.
- Patient Education: Offer appropriate information (clear, complete) regarding LDCT screening, including benefits, risks, and smoking cessation resources to enable the patient to make an informed decision.
How to Bill G0296: Step-by-Step
- Confirm Patient Eligibility: Age 50–80 (Medicare: 50–77), tobacco smoking history of at least 20 pack-years, smoker who currently smokes or has quit smoking in the last 15 years, and no symptoms of lung cancer.
- Hold and document the counseling visit: Offer a face-to-face( in person or telehealth) shared decision making session on LDCT screening and eligibility determination, risks/ benefits, smoking cessation counseling.
- Use the Correct Codes
- Bill G0296 for the counseling visit.
- Use appropriate ICD-10 codes:
- Current smoker: F17.210, F17.211, F17.213, F17.218, F17.219
- Former smoker: Z87.8914
- Submit the Claim: Ensure that all the requirements of documentation are met and attach supporting records when asked. There is no copay or deductible for patients that have Medicare.
- Coordinate with LDCT Screening: The LDCT Scan (71271 CPT) may be issued after G0296 at the applicable time.
- Retain Documentation: Keen record of eligibility, content of counseling, and shared decision making for audit.
G0296 vs. Related Codes
Code | Description | When Used |
G0296 | Counseling visit for LDCT lung cancer screening | Before the first LDCT screen |
71271 | Low-dose CT scan for lung cancer screening (replaces G0297) | For the actual scan |
Low-dose CT scan for lung cancer screening (deleted after 2020) | No longer in use |
Annual Screening and Follow-Up
After concluding the G0296 procedures of patient consultation and ordering a written prescription, one can move on to the procedure of LDCT scan coded by CPT code G0297. This Order of counseling followed by screening should be reiterated yearly while the patient is eligible and asymptomatic.
Annual eligibility needs to be monitored, and reminders are important, especially in long-term screening programs.
2025 CMS Updates for G0296
In 2025, G0296 is a CPT Medicare HCPCS code for mandatory counseling and shared decision-making before the first LDCT lung cancer screening visit. It’s for the adults aged 50–77 with at least a 20 pack-year smoking history who still smoke or quit within 15 years and have no lung cancer symptoms. The visit should include eligibility determination, screening for benefits/risks (using decision aids), and smoking cessation counselling. Documentation should include everything of these points and the LDCT written order. G0296 is free to Medicare patients and may be undertaken through telehealth. Codes for cessation of smoking cannot be billed on the same day (99406/99407). For current smokers, use the diagnosis codes F17.21x; for former smokers, use Z87.891. Reimbursement is guaranteed when proper documentation is provided and CMS guidelines are followed.
Conclusion
G0296 billing is not just a compliance check- it’s a critical point of lung cancer screening that is patient-centered and of high quality. By adhering to the up-to-date CMS guidelines, implementing best practices into your workflow, and implementing thorough documentation, you are guaranteed the best possible reimbursement and care for your patients.
Correct use of G0296 will not only help in early detection of lung cancer, but it will also enable meaningful conversations on issues concerned with prevention and health maintenance. Through sufficient staff training, EHR incorporation, audit readiness, and emphasis on patient education, your practice can venture ahead and successfully move through the ever-changing world of preventative care.
FAQ - People Also Asks
Can G0296 be billed more than once?
No. G0296 is billable only for the first counseling visit pre-initial LDCT screening. Other follow up annual screenings require a written order, and not another visit for counseling.
Can G0296 be billed with an Annual Wellness Visit?
Yes, but use modifier -25 to indicate a significant, separately identifiable service.
What if the patient is not eligible for screening?
Do not bill G0296 if the patient does not meet all eligibility criteria.
What if the patient is under 50 or over 77?
Medicare will not cover the counseling or screening for patients outside the eligible age range.