Coding Guidelines

The Balanced Budget Act of 1997, Section 4106 legislated coverage of bone mass measurements (BMMs) under Medicare.  This regulation defined BMM and individuals qualified to receive a BMM, established conditions for coverage under the “reasonable and necessary” provisions of 1862(a)(1)(A) of the Social Security Act, and established frequency standards governing when qualified individuals would be eligible for a BMM.  Per this Act, Medicare recognizes that these studies are beneficial to many Medicare patients; however, it is very important that physicians understand and apply Medicare’s coverage and coding guidelines in order for these services to be eligible under Medicare.

Medicare’s coverage of BMMs is provided through a National Coverage Determination (NCD) (150.3).  Processing guidelines, covered conditions, and frequency guidelines are found in the Internet-Only Manuals, Pub. 100-02, Chapter 15 § 80.5, and Pub. 100-04, Chapter 13, § 140.1.  The IOM is available at http://www.cms.hhs.gov/Manuals/IOM/list.asp.

The Centers for Medicare and Medicaid Services (CMS) issued CR 5847 that clarified claims processing instructions that were contained in CR 5521.  MLN Matters MM5521 and MM5847 were also issued and are available at http://www.cms.hhs.gov/mlnmattersarticles/

Under Medicare, coverage is provided for a BMM to monitor osteoporosis drug therapy, and as a preventive service for those patients meeting the criteria for a screening examination.

Effective January 1, 2007 the Centers for Medicare & Medicaid Services (CMS) has issued revised instructions and coverage for the benefits for bone mass measurements (BMM).  They are as follows:

A bone mass measurement (BMM) study is defined as a “radiologic or radioisotopic procedure or other procedure that meets all of the following conditions:

• Is performed to identify bone mass, detect bone loss, or determine bone quality;
• Is performed with a bone densitometer (other than single-photon or dual-photon absorptiometry (DPA)) or a bone sonometer (i.e., ultrasound) device approved or cleared for marketing for BMM by the Food and Drug Administration (FDA) under 21 CFR Part 807, or approved for marketing under 21 CFR Part 814;
• Includes a physician's interpretation of the results of the procedure.”

Medicare will cover a BMM when the following conditions are met:

• It is ordered by the physician or qualified nonphysician practitioner who is treating the beneficiary following an evaluation of the need for a BMM and determination of the appropriate BMM to be used.

Note: A physician or qualified nonphysician practitioner treating the beneficiary for purposes of this provision is one who furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results in the management of the patient. For the purposes of the BMM benefit, qualified nonphysician practitioners include physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives.

• It is performed under the appropriate level of physician supervision as defined in 42 CFR 410.32(b).
• It is reasonable and necessary for diagnosing and treating the condition of a beneficiary who meets the conditions described in the section below or in the IOM Pub 100-02 Medicare Benefit Policy, Chapter 15, §80.5.6.
• In the case of an individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy, is performed with a dual-energy x-ray absorptiometry system (axial skeleton).
• In the case of any individual who meets the conditions described in the section below or in the IOM Pub 100-02 Medicare Benefit Policy, Chapter 15, §80.5.6 and who has a confirmatory BMM, is performed by a dual-energy x-ray absorptiometry system (axial skeleton) if the initial BMM was not performed by a dual-energy x-ray absorptiometry system (axial skeleton). A confirmatory baseline BMM is not covered if the initial BMM was performed by a dual-energy x-ray absorptiometry system (axial skeleton).

In order for the BMM to be covered, a beneficiary must meet at least one of the five conditions listed below:

• A woman who has been determined by the physician or qualified nonphysician practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings.

Note:  Since not every woman who has been prescribed estrogen replacement therapy (ERT) may be receiving an “adequate” dose of the therapy, the fact that a woman is receiving ERT should not preclude her treating physician or other qualified treating nonphysician practitioner from ordering a bone mass measurement for her. If a BMM is ordered for a woman following a careful evaluation of her medical need, however, it is expected that the ordering treating physician (or other qualified treating nonphysician practitioner) will document in her medical record why he or she believes that the woman is estrogen-deficient and at clinical risk for osteoporosis.

• An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture.
• An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than 3 months.
• An individual with primary hyperparathyroidism.
• An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy.

Bill Type Codes

Revenue Codes

Types of Studies and Diagnoses Covered

The following CPT codes are used to describe the type of bone density measurement tests that are currently available and covered.

Patients who qualify by statute for osteoporosis screening may be evaluated by studies that are characterized by CPT codes 77078, 77079, 77080, 77081, 77083, 76977, and G0130. The following is a list of ICD-9-CM codes that support the medical necessity of osteoporosis screening.

Once the diagnosis of osteoporosis has been established, the effectiveness of treatment can ONLY be monitored using a dual energy x-ray absorptiometry (CPT code 77080).  The valid ICD-9-CM codes for the established diagnosis of osteoporosis are:

Peripheral scans are characterized by CPT codes 77078, 77079, 77081, 77083, 76977, G0130.  These scans are NOT covered for the monitoring of the effectiveness of osteoporosis therapy.  Therefore, if any of the following codes are the only codes submitted on the claim, the claim will NOT be covered.

Frequency of Studies

Medicare pays for a screening BMM once every 2 years (at least 23 months have passed since the month the last covered BMM was performed).

When medically necessary, Medicare may pay for more frequent BMMs. Examples include, but are not limited to, the following medical circumstances:

• Monitoring beneficiaries on long-term glucocorticoid (steroid) therapy of more than 3 months.
• Confirming baseline BMMs to permit monitoring of beneficiaries in the future.

Peripheral bone measurement scans are used primarily for screening purposes.  Peripheral bone measurement scans are not FDA-approved for continued follow-up of chronic conditions or osteoporosis treatment.  Therefore, peripheral studies (CPT/HCPCS codes 77078, 77079, 77081, 76977, G0130) would not be medically necessary more often than every two years.

Non-Covered Procedures

Medicare will not cover BMM claims for single photon absorptiometry (78350) effective January 1, 2007, or dual photon absorptiometry (78351) since 1983.

Additional References

Highmark Medicare Services provides coding guidelines for the preventive services eligible under Medicare, including bone mass measurement, in the  “Medicare Part B Preventive Services: Quick Reference Chart.”

MLN Matters MM5521 Revised

MLN Matters MM5847