Bone Mass Measurement (BMM) cpt - 76977, 77078 - 77083, g0130 and valid DX

This LCD clarifies national policy on Bone Mass Measurement (BMM) testing and defines the medically necessary indications for such studies.
Bone mass measurement is defined as a radiologic, radioisotopic or other procedure (e.g., ultrasound) that is:
  • Performed with a bone densitometer (other than Single Photon Absorptiometry [SPA] or Dual Photon Absorptiometry [DPA]) or a bone sonometer that has been approved or cleared for marketing 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.
  • Performed on an “eligible beneficiary” for the purpose of identifying bone mass, detecting bone loss or determining bone quality.
The term “eligible beneficiary” is defined in the Medicare statute as an individual who meets the medical indications for at least one of the following five categories:
  • A woman who has been determined by the physician or a qualified non-physician practitioner who is treating herto 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 non-physician 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 non-physician practitioner) will document in her medical record why he 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 (low bone mass) or vertebral fracture.
  • An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to 5.0mg of prednisone, or greater, per day, for more than three months.
  • An individual with primary hyperparathyroidism.
  • An individual being monitored to assess the response to, or efficacy of, FDA-approved osteoporosis drug therapy.
Tests that are not ordered by the appropriate physician or qualified non-physician practitioner are considered to be not reasonable and necessary. A physician or a qualified non-physician practitioner treating the beneficiary, for purposes of this LCD, 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.
Medicare will cover bone mass measurements when they are:
  • Ordered by the physician or qualified non-physician practitioner treating the beneficiary following an evaluation of the need for a measurement, including a determination as to the medically appropriate measurement to be used for that individual.
  • Furnished by a qualified supplier or provider of such services under at least a general level of supervision by a physician, as defined in 42CFR 410.32(b).
  • Reasonable and necessary for diagnosing, treating or monitoring an “eligible beneficiary” as defined in this LCD.
  • In the case of an individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy, BMM is performed with a DEXA system on the axial skeleton only (e.g., hips, pelvis, spine), and not on peripheral (or appendicular) anatomic sites (e.g., radius, wrist, heel).
  • A confirmatory BMM on an eligible beneficiary must be performed by a DEXA system on the axial skeleton, if the initial BMM was not performed by this type of test (that is, a DEXA system on the axial skeleton).
  • A confirmatory baseline BMM is not covered if the initial BMM was performed by a DEXA system on the axial skeleton.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 22X, 23X, 71X, 72X, 73X, 77X, 83X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
032X
CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
76977©
Us bone density measure
77078©
Ct bone density, axial
77079©
Ct bone density, peripheral
77080©
Dxa bone density, axial
77081©
Dxa bone density, peripheral
77083©
Radiographic absorptiometry
G0130
Single energy x-ray study
ICD-9-CM Codes that Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS code 77080:
Covered for:
252.00–252.01
Hyperparathyroidism
255.0
Cushing’s syndrome
256.2
Postablative ovarian failure
256.31
Premature menopause
256.39
Other ovarian failure
259.3
Ectopic hyperparathyroidism
627.2
Menopausal or female climacteric states
627.4
States associated with artificial menopause
627.9
Unspecified menopausal and postmenopausal disorder
733.00733.03
Osteoporosis, unspecified
733.09
Other osteoporosis
733.13
Pathologic fracture of vertebrae
733.90*
Disorder of bone and cartilage, unspecified
Note: Use 733.90* to indicate osteopenia.
758.6
Gonadal dysgenesis
805.00–805.08
Fracture of vertebral column without mention of spinal cord injury, cervical, closed
805.10–805.18
Fracture of vertebral column without mention of spinal cord injury, cervical, open
805.2–805.9
Fracture of vertebral column without mention of spinal cord injury
806.00–806.09
Fracture of vertebral column with spinal cord injury, cervical, closed
806.10–806.19
Fracture of vertebral column with spinal cord injury, cervical, open
806.20–806.29
Fracture of vertebral column with spinal cord injury, dorsal (thoracic), closed
806.30–806.39
Fracture of vertebral column with spinal cord injury, dorsal (thoracic), open
806.4–806.5
Fracture of vertebral column with spinal cord injury
806.60–806.62
Fracture of vertebral column with spinal cord injury, sacrum and coccyx, closed
806.69
Fracture of vertebral column with spinal cord injury, sacrum and coccyx fracture, closed, with other spinal cord injury
806.70–806.72
Fracture of vertebral column with spinal cord injury, sacrum and coccyx, open
806.79
Fracture of vertebral column with spinal cord injury, sacrum and coccyx, open, with other spinal cord injury
806.8–806.9
Fracture of vertebral column with spinal cord injury
V49.81*
Postmenopausal status (age-related) (natural)
*Note: Use V49.81* no more often than every two years.
V58.65
Long-term (current) use of steroids
Medicare is establishing the following limited coverage for CPT/HCPCS codes 76977, 77078, 77079, 77081, 77083and G0130:
Covered for:
252.00–252.01
Hyperparathyroidism
256.2
Postablative ovarian failure
256.31
Premature menopause
256.39
Other ovarian failure
259.3
Ectopic hyperparathyroidism
627.2
Menopausal or female climacteric states
627.4
States associated with artificial menopause
627.9
Unspecified menopausal and postmenopausal disorder
733.13
Pathologic fracture of vertebrae
758.6
Gonadal dysgenesis
805.00–805.08
Fracture of vertebral column without mention of spinal cord injury, cervical, closed
805.10–805.18
Fracture of vertebral column without mention of spinal cord injury, cervical, open
805.2–805.9
Fracture of vertebral column without mention of spinal cord injury
806.00–806.09
Fracture of vertebral column with spinal cord injury, cervical, closed
806.10–806.19
Fracture of vertebral column with spinal cord injury, cervical, open
806.20–806.29
Fracture of vertebral column with spinal cord injury, dorsal (thoracic), closed
806.30–806.39
Fracture of vertebral column with spinal cord injury, dorsal (thoracic), open
806.4–806.5
Fracture of vertebral column with spinal cord injury
806.60–806.62
Fracture of vertebral column with spinal cord injury, sacrum and coccyx, closed
806.69
Fracture of vertebral column with spinal cord injury, sacrum and coccyx fracture, closed, with other spinal cord injury
806.70–806.72
Fracture of vertebral column with spinal cord injury, sacrum and coccyx, open
806.79
Fracture of vertebral column with spinal cord injury, sacrum and coccyx, open, with other spinal cord injury
806.8–806.9
Fracture of vertebral column with spinal cord injury
V49.81*
Postmenopausal status (age-related) (natural)
*Note: Use V49.81 no more often than every two years.
V58.65
Long-term (current) use of steroids
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses that Support Medical Necessity
N/A
ICD-9-CM Codes that DO NOT Support Medical Necessity
N/A
Diagnoses that DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes that Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Appendices
N/A
Utilization Guidelines
Medicare is establishing the following general guidelines for the frequency of BMM:
Medicare may cover a bone mass measurement for a beneficiary once every two years (if at least 23 months have passed since the month the last bone mass measurement was performed). Examples of situations where more frequent bone mass measurements may be medically necessary include, but are not limited to, the following medical circumstances:
  • Monitoring beneficiaries on long-term glucocorticoid (steroid) therapy for more than three months.
  • Confirming baseline BMMs to permit monitoring of beneficiaries in the future.
  • Allowing for the assessment of patient response to FDA-approved osteoporosis drug therapy.
1) Allowed Frequencies for Axial Dual-Energy X-ray Absorptiometry (DEXA) Studies
Medicare will not allow axial DEXA studies (code 77080) more frequently than once every two years, except in the following three situations:
  • Patients with an established diagnosis of osteoporosis and who are being treated with FDA-approved osteoporosis drug therapy.
  • Patients who are being monitored because of medications that have a high likelihood of causing osteoporosis.
Note: Patients who will be placed on long-term glucocorticoid (steroid) therapy (e.g., transplant patients) should have a baseline axial bone mass measurement performed after beginning use of the medication. Claims for these studies should be submitted with ICD-9-CM code V58.65. Bone mass measurements performed on these patients prior to beginning use of a high-risk medication are considered to be screening tests and are non-covered.
  • Untreated patients with osteoporosis who refuse therapy and require close monitoring because of high risk for further bone loss.
In these three situations, one of the following ICD-9-CM diagnosis codes must be used:
733.00–733.03
Osteoporosis
733.09
Other osteoporosis
V58.65
Long-term (current) use of steroids
Axial DEXA studies (code 77080) performed for confirmatory purposes after any other type of BMMs were initially completed may be performed at any time subsequent to that study (codes 76977, 77078, 77079, 77081, 77083 and G0130).
Note: The confirmatory axial DEXA study must be submitted with a diagnosis code of osteoporosis or long-term glucocorticoid (steroid) therapy.
2) Allowed Frequencies for Studies Other Than Axial DEXA
  • BMM studies (codes 76977, 77078, 77079, 77081, 77083 and G0130), other than an axial DEXA study (77080), will not be allowed more frequently than once every two years.
3) Billing Multiple Studies on the Same Date of Service
  • Medicare reimbursement for a bone mass measurement, whether done by, DEXA, RA, QCT, SEXA or sonometry, is allowed only once on a given date, no matter how many sites are studied at that time. Two examples are as follows:
    • If the spine and heel are studied, either code 77080 or 77081 should be billed once, but not both codes (Exception: When a service billed with code 77080 was used for confirmatory purposes after a code 77081 service, and both were performed on the same day).
    • If the spine and heel are studied, either code 77078 or 77079 should be billed once, but not both codes.
Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.
Sources of Information and Basis for Decision
J4 (CO, NM, OK, TX) MAC Consolidation
TrailBlazer adopted the TrailBlazer LCD, “Bone Mass Measurement (BMM),” for the Jurisdiction 4 (J4) MAC transition.
Full disclosure of the sources of information is found with original contractor LCD.
Other Contractor Local Coverage Determinations
“Bone Mass Measurement (BMM),” TrailBlazer LCD, (00400) L16978, (00900) L16993.
Bone Mineral Density Studies,” Noridian Administrative Services LLC LCD, (CO) L23694 and L23890.
Bone Density Studies,” Arkansas BlueCross BlueShield (Pinnacle) LCD, (OK, NM) L13414.

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