TL;DR: The Centers for Medicare & Medicaid Services modified NCD 364 governing lung cancer screening with low dose computed tomography (LDCT), with an effective date of January 9, 2026. Here's what billing teams need to know.
CMS lung cancer screening coverage policy under NCD 364 Medicare tightened eligibility criteria and added documentation requirements that directly affect your claim submission process. This coverage policy applies to Medicare Part B beneficiaries who qualify for annual LDCT screening and the counseling visit that must precede it. The policy does not list specific CPT or HCPCS codes — your billing team should confirm the correct procedure codes with your Medicare Administrative Contractor (MAC) or billing consultant before submitting claims.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Centers for Medicare & Medicaid Services (CMS) |
| Policy | Lung Cancer Screening with Low Dose Computed Tomography (LDCT) |
| Policy Code | NCD 364 (364-v2) |
| Change Type | Modified |
| Effective Date | January 9, 2026 |
| Impact Level | High |
| Specialties Affected | Radiology, Pulmonology, Primary Care, Thoracic Surgery, RCM/Billing |
| Key Action | Audit patient eligibility documentation and verify counseling visit records before billing LDCT screening claims under Part B |
CMS Lung Cancer Screening Coverage Criteria and Medical Necessity Requirements 2026
The real risk here is the multi-layered eligibility check. CMS requires your billing team to confirm that every single criterion is met before submitting a claim. Miss one, and you're looking at a claim denial.
To satisfy medical necessity under NCD 364, a beneficiary must meet all five of the following criteria simultaneously:
| # | Covered Indication |
|---|---|
| 1 | Age: 50 to 77 years old |
| 2 | Asymptomatic: No signs or symptoms of lung cancer at the time of screening |
| 3 | Tobacco history: At least 20 pack-years (one pack per day for one year equals one pack-year; one pack equals 20 cigarettes) |
| 4 | Smoking status: Current smoker or someone who quit within the last 15 years |
| 5 | Order: A written order for lung cancer screening with LDCT must be in place |
Every one of these boxes must be checked. "Mostly meets criteria" is not billable. If the patient is 78, or their pack-year history is 18, or they quit smoking 16 years ago, Medicare does not cover the scan.
The counseling and shared decision-making visit is a separate, mandatory step — not optional documentation. Before a beneficiary receives their first LDCT screening, a qualifying counseling visit must occur and be documented in the medical record. This visit must cover shared decision-making using one or more decision aids, the importance of annual screening adherence, how comorbidities might affect diagnosis and treatment decisions, and smoking cessation counseling for current smokers or abstinence maintenance for former smokers.
That last point matters for reimbursement. If the counseling visit documentation is incomplete — missing the smoking cessation component, for example — your claim is exposed. Incomplete documentation is one of the most common reasons these claims fail on audit.
Prior authorization is not explicitly required under this NCD, but the counseling visit itself functions as a gatekeeping step. No counseling visit on record means no coverage for the subsequent LDCT. Treat the documentation requirement with the same urgency you'd give a prior authorization checklist.
CMS Lung Cancer Screening Exclusions and Non-Covered Indications
CMS is explicit: preventive services are not covered under Medicare unless a specific NCD grants coverage. That matters here because it means any LDCT screening that doesn't meet every eligibility criterion above is non-covered by default — there's no gray area or appeals pathway based on clinical judgment alone.
Symptomatic patients are excluded. If the beneficiary has signs or symptoms of lung cancer at the time of screening, this is no longer a preventive screening — it's a diagnostic workup, and different billing rules apply. Billing a diagnostic CT as a preventive LDCT screening is a compliance problem, not just a coding error.
Patients outside the 50–77 age range are not covered. A 48-year-old heavy smoker with a strong family history does not qualify under this NCD. Neither does a 79-year-old who otherwise meets every other criterion. Age cutoffs are hard limits under this coverage policy.
Patients whose pack-year history falls below 20 or who quit smoking more than 15 years ago do not qualify. Document the pack-year calculation and quit date explicitly in the record. If your provider is estimating these figures rather than documenting them, that's a problem worth addressing before January 9, 2026.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Annual LDCT lung cancer screening — eligible beneficiary (age 50–77, 20+ pack-years, current/recent smoker, asymptomatic, with order) | Covered | Not specified in policy | Requires prior counseling and shared decision-making visit; annual screening benefit |
| Counseling and shared decision-making visit (first-time LDCT screening) | Covered | Not specified in policy | Must precede first LDCT; full documentation required including smoking cessation counseling |
| LDCT screening for symptomatic patients (signs or symptoms of lung cancer present) | Not Covered | Not specified in policy | These patients require diagnostic workup, not preventive screening |
| LDCT screening for patients outside age range (under 50 or over 77) | Not Covered | Not specified in policy | Hard age cutoffs; no exceptions under NCD 364 |
| LDCT screening for patients with fewer than 20 pack-years | Not Covered | Not specified in policy | Pack-year history must be documented explicitly |
| LDCT screening for former smokers who quit more than 15 years ago | Not Covered | Not specified in policy | Quit date must be documented; claims outside this window will deny |
| LDCT at facilities without a standardized nodule classification system (e.g., Lung-RADS) | Not Covered | Not specified in policy | Facility must use a standardized lung nodule identification, classification, and reporting system |
| LDCT read by non-board-certified/non-board-eligible radiologist | Not Covered | Not specified in policy | Reading radiologist must hold ABR board certification or equivalent |
CMS Lung Cancer Screening Billing Guidelines and Action Items 2026
LDCT screening billing under NCD 364 has more failure points than most preventive services. Here's what to do before and after the January 9, 2026 effective date.
| # | Action Item |
|---|---|
| 1 | Audit your eligibility verification workflow before January 9, 2026. All five eligibility criteria — age, asymptomatic status, pack-year history, smoking status, and written order — must be confirmed and documented before the scan. Build a checklist into your intake or order process. One missing element triggers a denial. |
| 2 | Confirm your facility meets the radiology imaging requirements. The scanning facility must use a standardized lung nodule identification, classification, and reporting system. Lung-RADS (from the American College of Radiology) is the most widely used system that satisfies this requirement. If your facility doesn't use a qualifying system, these claims are not billable under NCD 364 — full stop. |
| 3 | Verify reading radiologist credentials before submitting claims. The radiologist interpreting the LDCT must be board certified or board eligible with the American Board of Radiology or an equivalent organization. If your practice uses locum or contracted radiologists, confirm their credentials now. This is an easy compliance gap to miss and a straightforward denial reason. |
| 4 | Review counseling visit documentation for completeness. Every first-time LDCT patient needs a documented counseling and shared decision-making visit covering all four required elements: eligibility confirmation, shared decision-making with a decision aid, comorbidity counseling, and smoking cessation or abstinence counseling. A note that simply says "counseling provided" won't hold up. The medical record needs to reflect each component. |
| 5 | Confirm the correct procedure codes with your MAC. This policy does not list specific CPT or HCPCS codes. Contact your Medicare Administrative Contractor to confirm the current codes for both the counseling visit and the LDCT screening itself before submitting claims. Using outdated or incorrect codes against this NCD is an easy claim denial to avoid with a single phone call. |
| 6 | Separate diagnostic and preventive billing workflows. If a patient arrives with symptoms, that encounter is diagnostic — not preventive. Train your clinical and billing staff to flag symptomatic presentations and route them to the correct diagnostic CT pathway. Billing a symptomatic scan as preventive LDCT creates both a denial risk and a compliance exposure. |
| 7 | Talk to your compliance officer if your volume is high. If your practice or facility screens a large number of Medicare patients for lung cancer, the documentation requirements here carry significant financial and compliance exposure. A compliance review of your current workflow — before the effective date — is worth the investment. If you're not sure whether your current process satisfies NCD 364's counseling and facility requirements, loop in your compliance officer or billing consultant now. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Lung Cancer Screening with LDCT Under NCD 364
A Note on Code Availability
This policy does not list specific CPT, HCPCS, or ICD-10 codes. The NCD 364 policy document does not include a code table, and we will not invent codes that aren't in the source material.
For LDCT lung cancer screening billing, your team should contact your MAC directly or reference the CMS Preventive Services coding resources to confirm the current procedure codes. Common code types that apply to this service area include codes for the counseling/shared decision-making visit and the LDCT scan itself — but confirm the exact codes with your MAC before submitting claims under this NCD.
Billing LDCT screening with incorrect codes is one of the most avoidable denial reasons in this service category. Don't assume the codes haven't changed.
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