The new Balanced Budget Amendment, signed into law, mandates preventative care for high risk individuals, and guarantees Bone Density Reimbursement even if the test is negative and also requires all states to pay for the codes below starting July 1998.
CPT Code 77080 - Hip, spine or central DEXA (Dual Energy X-Ray Absorptiometry) studies. Fee amoumt $40.41
CPT Code 77081 - Peripheral DEXA Bone Mineral Density - $27.72
CPT Code 77082 - Peripheral Ultrasound Bone Mineral Density
Effective for dates of service on or after January 1, 2007, Medicare will pay for BMM services for dual-energy x-ray absorptiometry (CPT code 77080) when this procedure is used to monitor osteoporosis drug therapy. In addition, new CPTs were assigned to BMMs.
• Effective for dates of service on and after January 1, 2007, the CY 2007 Physician Fee Schedule final rule expanded the number of beneficiaries qualifying for BMM by reducing the dosage requirement for glucocorticoid (steroid) therapy from 7.5 mg of prednisone per day to 5.0 mg. It also changed the definition of BMM by removing coverage for a single-photon
absorptiometry (SPA) as it is not considered reasonable and necessary under section 1862 (a)(1)(A) of the Act.
• Effective for dates of services on and after January 1, 2007, the following changes apply to BMM:
• New 2007 CPT bone mass codes have been assigned for BMM. The following codes will replace current codes, however the CPT descriptors for the services remain the same:
77078 replaces 76070 77081 replaces 76076
77079 replaces 76071 77083 replaces 76078
77080 replaces 76075
• BMM is not covered when a procedure other than dual-energy x-ray absorptiometry is used to monitor osteoporosis drug therapy. Therefore, Medicare will not pay for procedure codes 76977, 77078, 77079, 77081, 77083 and G0130 when billed with the following ICD-9-CM diagnosis codes:
733.00 733.01 733.02 733.03 733.09 733.90 255.0
• BMM is covered when dual-energy x-ray absorptiometry is used to monitor osteoporosis drug therapy. Therefore, Medicare will pay procedure code 77080 when billed with the following ICD-9-CM diagnosis codes or any of the other valid ICD-9-CM diagnoses that are recognized by Medicare contractors appropriate for bone mass measurements:
733.00 733.01 733.02 733.03 733.09 733.90 255.0
Coverage Indications, Limitations, and/or Medical Necessity
Bone (mineral) density studies are used to evaluate diseases of bone and/or the responses of bone diseases to treatment. The studies access bone mass or density associated with such diseases as osteoporosis, osteomalacia, and renal osteodystrophy. Various single or combined methods of measurement may be required to: (a) diagnose bone disease, (b) monitor the course of bone changes with disease progression, or (c) monitor the course of bone changes with therapy.
Covered methods for measuring bone mineral density include:
· Single energy x-ray absorptiometry (SEXA)
· Dual energy x-ray absorptiometry (DXA)
· Quantitative computed tomography (QCT)
· Bone ultrasound densitometry (BUD)
· Radiographic absorptiometry (RA)
The following bone mass measurements are NOT covered under Medicare because they are not considered reasonable and necessary under section 1862(a)(1)(A) of the Act:
· Single photon absorptiometry (SPA), CPT code 78350 (effective 01/01/2007)
· Dual photon absorptiometry (DPA), CPT code 78351
Bone density can be measured at the wrist, spine, hip or calcaneus. The medical literature is divided on the accuracy of predicting osteoporosis of the spine or hip by measuring peripheral sites (wrist, calcaneus). It does appear, however, that measurement of bone density of the bone involved gives a better measurement of osteoporosis than does measurement of another bone not known to be involved.
Precise calibration of the equipment is required for accuracy and to reduce variation of test results and risk of misclassification of the degree of bone density. Lack of standardization in bone mineral measurement remains an issue, and tests are best done on the same suitably precise instrument to insure accuracy. It is important to use results obtained with the same scanner when comparing a patient to a control population, as systematic differences among scanners have been found. To ensure reliability of bone mass measurements, the densitometry technologist must have proper training in performing this procedure. Malpositioning of a patient or analyzing a scan incorrectly can lead to great errors in bone mineral density studies.
Medicare considers a bone mineral density study to be medically reasonable and necessary for the following indications: In addition, all coverage criteria listed below must be met.
1. A patient with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral fracture.
2. A patient being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy. This service must be performed using dual energy x-ray absorptiometry system (axial skeleton) – CPT codes 77080 and 77085.
3. A patient with known primary hyperparathyroidism.
4. A patient 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.
5. A woman who has been determined by the physician or a qualified non physician 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) maybe 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 bone mass measurement 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 estrogen-deficient woman qualifies if she is at clinical risk for osteoporosis, based on her medical history and other findings. Unless this applies and is documented in the medical record, the service is not payable.
In addition to gender and estrogen-deficiency, pertinent factors acceptable as documentation for the clinical risk include, but are not limited to: age, family history and personal history of fractures as an adult, race, bone structure and body weight, premature menopause, lifestyle, medications, chronic diseases, and other genetic and environmental factors. Symptoms and findings of osteoporosis include, but are not limited to: back pain, loss of height, curving spine, and chest x-ray showing osteopenia.
Bone density measurement is not a covered Medicare benefit when utilized for osteoporosis screening in an estrogen-deficient woman, who has not been determined by the physician or a qualified nonphysician practitioner treating her to be at clinical risk for osteoporosis, based on her medical history and other findings.
If - in addition to gender and estrogen-deficiency - a woman has been determined to be at clinical risk for osteoporosis, based on her history and other findings, and this has been appropriately documented in the medical record, this Carrier will interpret the menopausal state as symptomatic.
COVERAGE CRITERIA FOR BONE MASS MEASUREMENTS
1. There must be an order by the individual’s physician or qualified nonphysician practitioner treating the patient following an evaluation of the need for a measurement, including a determination as to the medically appropriate measurement to be used for the individual. 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 purpose of the bone mass measurement benefit, qualified nonphysician practioners include physician assistants, nurse practioners, clinical nurse specialists and certified nurse midwives.
2. This service must be furnished by a qualified supplier or provider of such services under the appropriate level of physician supervision as defined in CFR 410.32(b);
3. This service must be reasonable and necessary for diagnosing, treating, or monitoring a qualified individual as defined above; and
4. This service is a radiologic or radioisotopic procedure which must be performed with a bone densitometer or a bone sonometer system cleared for marketing by the FDA, under 21 CFR part 807 or approved for marketing under 21 CFR part 814 for identifying bone mass or detecting bone loss or determining bone quality, with the exception of dual photon absorptiometry devices.
Medicare may cover a bone mass measurement for a patient once every 2 years. However, if medically necessary, Medicare may cover a bone mass measurement for a patient more frequently than every 2 years. Examples of situations where more frequent bone mass measurements procedures may be medically necessary include, but are not limited to, the following medical circumstances:
· Monitoring patients on long-term glucocorticoid (steroid) therapy of more than 3 months; and
· In the case of any individual who meets the conditions as defined above, 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).
· Monitoring a patient to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy if the result is being used to determine the need for continued treatment of osteoporosis. Agents approved by the FDA for osteoporosis prevention and/or treatment include:
o estrogen therapy (for purposes of this policy, the estrogen must be specifically used for treatment of osteoporosis)
o alendronate (Fosamax)
o calcitonin-salmon (Miacalcin-nasal spray or injection)
o raloxifene (Evista)
o risedronate sodium (Actonel/Atelvia)
o teriparatide (Forteo) injection
o ibandronate (Boniva)
o zoledronic acid (Reclast) injection
o denosumab (Prolia)
· To determine a patient’s response to pharmacologic therapy when the therapy has been changed to another family of therapeutic agents
Vertebral fracture assessment (CPT code 77086) is not within the scope of this LCD and is, therefore, subject to individual consideration.
Indications for DEXA
* Crush fractures of the spine
* Long-term corticosteriod use
* To monitor course of therapy
* Recent fracture of hip, spine, etc.
Bone mineral density (BMD) can be measured with a variety of techniques in a variety of sites. Sites are broadly subdivided into central sites (e.g. hip or spine) and peripheral sites (e.g. wrist, finger, heel). While BMD measurements are predictive of fragility fractures at all sites, central measurements of the hip and spine are the most predictive. Additionally, fractures of the hip and spine (e.g. vertebral fractures) are the most clinically relevant. The most commonly used techniques are Dual X-ray Absorptiometry (DXA), Quantitative computed tomography (QCT), and Ultrasound Densitometry.
Dual-energy x-ray absorptiometry (DXA) is considered the gold standard because it is the most extensively validated test against fracture outcomes. In general, a central DXA BMD measurement should be strongly considered for initial screening purposes due to its reproducibility and ability to simultaneously establish the diagnosis of osteoporosis and provide a baseline if one is needed. This approach is endorsed by the National Osteoporosis Foundation’s Clinician’s Guide to Prevention and Treatment of Osteoporosis as well as the Michigan Quality Improvement Consortium Guideline: Management and Prevention of Osteoporosis
Billing and Coding Guideline
The below code would not be paid when billing with cpt code 77080 , use correct modifier
New 2007 CPT bone mass codes have been assigned for BMM. The following codes will replace current codes, however the CPT descriptors for the services remain the same:
77078 replaces 76070
77081 replaces 76076
77079 replaces 76071
70830 replaces 76078
77080 replaces 76075
If the initial BMD measurement was medically necessary as defined above, serial measurements of BMD to monitor treatment response may be considered medically necessary when performed no more frequently than 24 months apart and when a change in treatment plan may be made based on BMD results. When the need for serial measurements is anticipated in high risk patients who are likely to require treatment, and for obtaining serial measurements, a central DXA BMD measurement should be obtained, as treatment related changes in BMD are not observed at peripheral sites
More frequent bone mass measurements may be considered medically necessary in any of the following circumstances:
1. Monitoring individuals on long-term glucocorticoid (steroid) therapy of more than 3 months duration; or
2. For a confirmatory baseline bone mass measurement to permit monitoring of individuals in the future if the initial bone mass test was performed with a technique that is different from the proposed testing method; or
3. Monitoring of individuals with uncorrected primary hyperparathyroidism.
The procedure must be ordered by a physician or qualified practitioner after a complete assessment of the patient’s condition determines that a bone mass measurement is medically necessary. If diagnosis, frequency, or documentation does not support medical necessity, coverage will be denied. The need for bone mass measurement more frequently than every 2 years must have documentation defining the medical necessity. Documentation must include the complete medical record including
previous bone densitometry study results and any other pertinent test findings, medication lists, and office notes. Letters summarizing the medical record may be useful, but are not considered adequate documentation
BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.
ICD-10 Diagnoses that support screening central DEXA (77080, 77085) for commercial members (for dates of service on or after October 1, 2015):
Z00.00 Encounter for general adult medical examination without abnormal findings
Z00.01 Encounter for general adult medical examination with abnormal findings
Z13.820 Encounter for screening for osteoporosis
Z78.0 Asymptomatic menopausal state
ICD-10 Codes that Support Medical Necessity
E21.0 Primary hyperparathyroidism
E21.1 Secondary hyperparathyroidism, not elsewhere classified
E21.2 Other hyperparathyroidism
E21.3 Hyperparathyroidism, unspecified
E24.0* Pituitary-dependent Cushing's disease
E24.2* Drug-induced Cushing's syndrome
E24.3* Ectopic ACTH syndrome
E24.4* Alcohol-induced pseudo-Cushing's syndrome
E24.8* Other Cushing's syndrome
E24.9* Cushing's syndrome, unspecified
E28.310 Symptomatic premature menopause
E28.319 Asymptomatic premature menopause
E28.39 Other primary ovarian failure
E89.40 Asymptomatic postprocedural ovarian failure
E89.41 Symptomatic postprocedural ovarian failure
M48.40XA Fatigue fracture of vertebra, site unspecified, initial encounter for fracture
M48.41XA Fatigue fracture of vertebra, occipito-atlanto-axial region, initial encounter for fracture
M48.42XA Fatigue fracture of vertebra, cervical region, initial encounter for fracture
M48.43XA Fatigue fracture of vertebra, cervicothoracic region, initial encounter for fracture
M48.44XA Fatigue fracture of vertebra, thoracic region, initial encounter for fracture
M48.45XA Fatigue fracture of vertebra, thoracolumbar region, initial encounter for fracture
M48.46XA Fatigue fracture of vertebra, lumbar region, initial encounter for fracture
Commonly Used ICD-9 CodesICD-9 Diagnosis
255.0 Cushing Syndrome
*256.2 Post Oblative Ovarian Failure - Age 40 and below
*256.3 Primary Ovarian Failure - Age 40 and below
256.30 Premature Osteoporosis
+256.8 Ovarian Dysfunction
257.2 Testicular Dysfunction
268.2 Osteomalacia/Osteoporosis Syndrome
269.1 Mineral Deficiency
307.1 Anorexia Nervosa/Bulimia
579.8 Malabsorption of Calcium
585.0 Chronic Renal Failure
588.0 Renal Osteodystrophy
588.8 Secondary Hyperparathyroidism
+627.20 Menopausal Syndrome
714.0 Rheumatoid Arthritis
*733.00 General Osteoporosis
*733.01 Postmenopausal or Senile Osteoporosis
*733.02 Idiopathic Osteoporosis
733.03 Disuse Osteoporosis
*733.09 Drug Induced Osteoporosis
*733.8 Diabetic Bone Changes
*733.09 Use with Patients on Following Drugs: Corticosteroids, Heparin, Phenytoin, Thyroid Replacements (only if TSH Level is Subnormal)
*805.2 Fracture of Thoracic Spine,Closed
*806.4 Fracture of Lumbar Spine, Closed
*807.01 Fracture of Rib, Closed, One Rib
*807.02 Fracture of Rib, Closed,Two Ribs
*808.0-808.9 Fracture of Pelvis
*820.0-820.9 Fracture of Neck Femur
*808.00 Pelvic Fracture
*813.41 Colles Fracture
*814.00 Wrist Fracture
*V58.69 Long Term (current) use of high risk medication. (Generally used with 733.09)
(+) Can be used in some states now (Not in Tennessee). Can be used after July 1, 1998 in all states along with all other codes listed.
(*) To get paid on negative or osteopenic studies one must use a code with (*) by it until July 1, 1998. Then all codes listed are acceptable for high risk (perimenopausal) individuals with two or more of the following risk factors:• White or Asian Ancestry
• Excess Alcohol Consumption
• Low Body Weight
• Advanced Age
• Early Menopause
• Smoking History
• Family History of Osteoporosis
• Inadequate Calcium Intake
• Inactive Lifestyle
• Previous Fracture