Thanks to all who attended our webinar presented by Kim Parham, "A Fresh Look at Lung Cancer Screening - Incidental Findings and Organized Screening...It Can Be Done". See below for the answers to the questions asked during the presentation.
For access to the recorded webinar, please click here.
1. What are some best practices for outreach to bring appropriate patients in for screening?
Best is outreach to the PCP that knows the patient and can encourage them to enroll in smoking cessation and start annual lung screenings. PCP’s are sometimes hard to reach. Start with ground rounds or any continuing medical updates your facility may have. Also by having physician champions encouraging and talking to PCP’s is crucial. Physician liaisons or account executives that go around to physician’s offices already have relationships in the community so letting them have the brochures, order forms, etc would be a way to reach the outlying referring physicians that may not be on campus.
To outreach to patients, billboards typically do not get much return on investment but in your community, it may be worthwhile. Direct mail/postcards from previous patients identified as high risk via your EMR. Have educational brochures throughout your facility and physician’s offices. Educate your other team members in other screening areas about your program so they can encourage other screenings (for example-in mammography-they can help identify if a patient would qualify for LDCT screening and/or colonoscopy). Large employers, factories, and sporting events would all be good areas to concentrate outreach efforts.
2. For the incidental findings, are ERs only the first step? What about all CTs, regardless of entry?
The answer is yes to a lung nodule or high risk clinic. It is good to pilot first in one area working out any issues and take to a broader base. Initially, we started with one ER and then involved radiology to tag the navigators for any imaging anywhere performed including ER, inpatient and outpatient. Your program leadership can help set parameters for notification. If your goal is also hospital risk reduction, you will want to get involved with smaller than 8mm nodules by just making sure the patient and PCP knows and to follow up. If your leadership only wants 8mm nodules to enter a lung nodule clinic, then that would be your leadership’s decision. Unless small community with all the PCP’s agreeing or academic centers, I would always let the PCP determine next steps. We learned early on that sometimes there may have been a stable nodule that the PCP knew was there but the radiologist or hospital did not have access to that information.
3. Can you name a few of the lung screening genomic testing companies you mentioned on the broadcast?
The test that can augment a screening program is Oncimmune. It is an autoantibody test that can be utilized if a patient cannot get insurance to cover a LDCT screen because they are under 55 but still meet NCCN guidelines-2nd category because of exposure to chemicals or may not have access to LDCT screening. The test will show risk stratification of low, moderate or high risk. Many PCP’s are ordering this test. Several hospitals have placed this in their algorithm flow charts once a nodule is found. The blood test is covered by Medicare and most insurances.
There are also tests that once you find a nodule. Gensignia is a micro RNA signature classifier. This could also be placed in flow charts.
Another test Veracyte Perceta. Percepta is a bronchial genomic classifier that is beneficial after the bronchoscope yields are inconclusive. It utilizes bronchial epithelial cells.
There are many genomic tests available once a cancer is detected but these are 3 newer technology tests out now to help identify lung cancers earlier.
4. In your program you profiled, what actually happened from an IT perspective to support your team?
For our Emergency room patients, our Cerner team built a drop down for the ER physicians to click and we were able to run daily reports from this field. It would also let the patient know in their discharge instruction sheet that they had an abnormal finding and a navigator would be calling them within 48 hours.
For radiology identified incidental nodules, the radiologists created a “PN” pulmonary nodule category to code similar to their critical result findings and we would run daily reports. We kept up with patients utilizing a home grown developed Access data base and excel spreadsheet. We really needed something electronically since everything was manual. LDCT screening was different technology and now with automation, we were notified differently.
There are now automated letters and numerous registries available on the market to help with the required data elements and follow up required for CMS submittal. Also, there are programs that will help track and follow up on incidental findings.
5. In your Lung/Thoracic Conference do you report on the screening and incidental findings, as a whole - or only the ones that end up with a malignancy?
It is all dependent on the physicians. I think most programs bring to the conferences Lrads 4 and some bring Lrads 3 since they are at high risk. Many times it is clinic patients that were referred to the program some were outside referrals to our physicians and not identified with our imaging department. Several times patients are brought without diagnosis and some with diagnosis. In a large community setting, it is good to have the physicians decide who and how they want patients presented. In academic or smaller community settings, it is easier to a definite pathway on presentation.
6. Does LDCT require an order?
Yes. CMS issued NCD 210.14 on August 21, 2105, that provides for Medicare coverage of screening for lung cancer with LDCT. Effective for claims with dates of service on and after February 5, 2015, 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 (one pack-year = smoking one pack per day for one 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.
7. What do you consider to be best-practice elements of a Lung Screening Program?
A way to verify shared decision making has occurred and smoking cessation has been discussed. This seems to consistently be a concern nationwide. In some centers, a nurse will make sure this has happened or it is part of their role. In other centers, it is the responsibility of the referring provider.
This will need to be documented and the shared decision making billing code will need to have occurred. Paper orders can have places where the ordering physician can verify they have provided the education and discussion. If electronic orders are submitted, fields can be created verifying the same information for the order to go through.
I like to think of the LDCT screening test like a diagnostic mammogram since there are requirements around doing the diagnostic imaging, there are requirements for doing this type of screening. Centers are getting reimbursed by CMS but need to make sure they have the correct elements documented in case of audits.
8. What is the average self-pay charge for LDCT?
Some places are doing self-pay and others have stopped promoting self-pay making sure authorization is required. Then they will follow up if an authorization cannot be obtained. For self-pay, most are charging in between what their Medicare reimbursement and most common insurance reimbursements are covering. You do not want to charge a low amount and common insurers find out and lower their reimbursements.
9. Is Medicare reimbursing or are claims being held up?
If elements are submitted properly, I have not heard of them being held up. However, I have heard of organizations where they are having a hard time submitting the required data.
10. Are programs required to report to the ACR Lung Cancer Screening Registry?
As of now, yes since they are the only one approved by CMS.
11. Do you recommend that lung programs publish their results in the local newspaper, etc for goodwill marketing?
Never thought of publishing in a local newspaper results. I think that might be a good way to reach the population that needs the screening. If you are locally catching a significant number of early stage lung cancers, then yes it would be an excellent outreach tool. The population that needs to be screened are still a population that reads the paper so taking out an ad would be a good use of marketing funds. A better idea would be combining the data with a lung cancer screening patient story that found an early stage lung cancer and is doing well. Papers sometimes will use the stories for free especially with promoting November’s lung cancer awareness month as the opportunity.
12. Do you have experience with navigation programs led by a mid-level provider (NP or PA)? What was the process flow?
I have seen a NP or PA that run the screening clinic have certain days where the patients come in and they do the shared decision making and smoking cessation discussion. They bill and make sure the test is ordered appropriately. It seems to work best if they have the exam immediately afterwards but some clinics, have the patient think about the information and come back another day. The NP or PA then also help with follow up and tracking. In a low volume facility, they could also help run the lung nodule clinic.
13. What are best practices for collecting and submitting data to the ACR lung registry?
Having an automation process is crucial, especially if you are a large volume clinic and following up on incidentals as well. Having different charting areas has the chance to forget following up on patients.
The ACR has programs listed that can submit to the registry. Also think about other EMR software that will follow patients throughout survivorship. The software may be able to collect the data elements required and submit to ACR capabilities, plus the software will help the navigators throughout the patient’s care journey.
I think it is also important for everyone to know their expected role. Since this is new, everyone is trying to find the best process within their center. Some centers have specially trained lay navigators or clinic staff make sure the order is correct while others have NP’s or PA’s that have ownership for eligibility and the entire management process including registry submission. Other centers have trained lay navigators or clinic staff make sure the order is correct and a dedicated radiology technologist follows up with the patient.
Several facilities utilize a hybrid method and ownership. Radiology and imaging owns the eligibility and reporting but depend on navigation (typically falling under oncology) for the follow up and reporting of the patient’s continuum so that the radiology team submits to CMS. As lung programs grow, breakout lung screening and nodule programs may develop their own specialty team within a community practice similar to large mammography centers. Getting started, it seems the hybrid model or starting with a NP/PA to determine eligibility are the main programs. It may be hard to justify having a NP/PA to oversee unless downstream revenue is tracked carefully and engaged physician champions promote the program to administration.
14. What types of technology (tools, platforms, resources) have you found most helpful in designing and implementing your program?
Most programs that started with cash pay years ago, used spreadsheets to manage and track patients. Now there are so many programs available, automation like mammography is key. If you have not started with an automated program, I would first see what program mammography is using for their data tracking for MQSA. If the radiologist and breast imaging team are happy with their product, check to see if they make a lung program. Most centers have relationships with the sales team and the product would be an approved vendor to help expedite the purchase. When we started we utilized excel spreadsheets and Access data base. Check with your oncology team to see if they are using management software like Cordata that can help manage and track your screening patients.
15. Can you describe some of the Cordata features that support lung screening programs?
- Availability of LDCT Screening Survey (email or text to patients)
- LDCT/Chest CT order event capture
- LDCT/Chest CT results event capture (Lung-RAD, nodule presence, size/description and follow up)
- LDCT/Chest CT downstream events capture and coordinator reminder such as bronchoscopy, surgery, medical oncology, radiation oncology, genetic testing (FGFR1 and DDR2 as well as PIK3CA) and survivorship surveillance
- Lung coordinator reminders for all events
- Lung conference agenda, notes (CoC required elements) and CoC report of annual totals.
Did the Lung Cancer Screening Webinar spark your interest?
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