Bone Mass Measurement (L31620)
Contractor Information
|
Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
Document Information
L31620 LCD Title Bone Mass Measurement Contractor's Determination Number MS-004 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 08/15/2011 Original Determination Ending Date Revision Effective Date For services performed on or after 04/01/2012 Revision Ending Date |
CMS National Coverage Policy
CMS Pub. 100.4 13 §140-140.3; 100-4 13 §10-10.1; 100-4 23 §10-10.1.7;
CMS Pub. 100-3, Medicare National Coverage Determinations, Ch. 1, Part 2, §150.3
CMS Pub.100-2, Ch. 15, §80.5
CMS Pub. 100-3, Medicare National Coverage Determinations, Ch. 1, Part 2, §150.3
CMS Pub.100-2, Ch. 15, §80.5
Indications and Limitations of Coverage and/or Medical Necessity
Abstract
Bone mass measurement (BMM) studies are radiologic, radioisotopic or other procedures that meet all of the following conditions:
1. Quantify bone mineral density, detect bone loss or determine bone quality;
2. Are performed with either a bone densitometer (other than single-photon or dual-photon absorptionmetry) or a bone sonometer system that has been 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.
3. Include a physician's interpretation of the results
The following procedures are used to measure bone mineral density:
1. Dual energy x-ray absorptiometry (DXA)
2. Radiographic absorptiometry (RA)
3. Bone sonometry (ultrasound)
4. Single energy x-ray absorptiometry (SEXA)
5. Quantitative computed tomography (QCT)
Earlier technologies, such as single and dual photon absorptiometry (CPT codes 78350 or 78351) are no longer used.
Indications
A. Medicare covers a bone mass measurement (BMM) for a beneficiary once every two years (if at least 23 months have past since the month the last bone mass measurement was performed). The criteria for bone mass measurement every two years are listed below;
1. It is performed with a bone densitometer, other than dual photon absorptiometry (DPA) or a bone sonometer (e.g., ultrasound) device that has been approved or cleared for marketing by the Food and Drug Administration (FDA).
2. It is performed on a qualified individual for the purpose of identifying bone mass, detecting bone loss or determining bone quality. The term "qualified individual" means an individual who meets the medical indications for at least one of the criteria listed below:
a. A woman who has been determined by the physician or a qualified non-physician treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other indicators.
b. An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral fracture.
c. An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to 5 mg of prednisone, or greater, per day for more than three months.
d. An individual with primary hyperparathyroidism,
e. An individual being monitored to assess the response to or efficacy of an FDA approved osteoporosis drug therapy.
3. If it is furnished by a qualified supplier or provider of such services, under at least the general level of supervision of a physician as defined in section 1861 of the Social Security Act.
4. If the test is ordered by the individual's physician or qualified non- physician practitioner, who is treating the beneficiary following an evaluation of the need for the measurement, including a determination as to the medically appropriate measurement to be used for the individual, and who uses the results in the management of the patient.
5. The test is reasonable and necessary for diagnosing, treating or monitoring of a "qualified" individual as defined above.
B. For conditions specified below, Medicare will cover a bone mass measurement for a qualified beneficiary more frequently than every two years, if medically necessary for the diagnosis or treatment of the patient and if related to the condition listed. To be considered at least eleven months must have elapsed since the previous bone mass measurement test. Such conditions are;
1. Monitoring beneficiaries on long-term glucocorticoid (steroid) therapy, equal to 5 mg of prednisone or greater, for more than three months. (Patients must be on glucocorticoids for greater than three months duration, but BMM monitoring is at yearly intervals).
2. Confirming baseline BMMs to permit monitoring of beneficiaries in the future. (CMS Publication 100-02, Ch. 15, §80.5.5).
In addition, bone mass measurement for the following may be reimbursed more frequently than every two years:
3. Follow up bone mineral density testing to assess FDA-approved osteoporosis drug therapy until a response to such therapy has been documented over time.
C. Medicare will cover a confirmatory baseline bone mass measurement when it is performed with a dual energy x-ray absorptionmetry system (axial skeletal) to permit monitoring of beneficiaries in the future, if the initial test was performed with a technique that is different from the proposed monitoring method (for example, if the initial test was bone sonometry and the patient will be monitored with bone densitometry, a second test utilizing densitometry will be paid). If the initial bone mass measurement was performed by a dual-energy x-ray absorptionmetry system (axial skeletal), than a confirmatory BMM is not covered.
D. There are multiple techniques for obtaining bone mass or bone density information. There is a difference in the precision, and accuracy of the different techniques and the sensitivity of measurement in axial (central) or peripheral sites. In general, because cancellous bone changes more rapidly in time and with therapeutic intervention, the sites of cancellous bone (lumbar spine, proximal femur) are more likely than peripheral sites or cortical bone to show a response to FDA approved osteoporosis drug therapy and are preferred for baseline and drug monitoring purposes. The most reliable comparative results for drug monitoring are obtained when the same BMM instrument is used. Based on this, Medicare coverage is limited to those techniques which have been rated favorably in clinical studies.
Bone mass measurement (BMM) studies are radiologic, radioisotopic or other procedures that meet all of the following conditions:
1. Quantify bone mineral density, detect bone loss or determine bone quality;
2. Are performed with either a bone densitometer (other than single-photon or dual-photon absorptionmetry) or a bone sonometer system that has been 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.
3. Include a physician's interpretation of the results
The following procedures are used to measure bone mineral density:
1. Dual energy x-ray absorptiometry (DXA)
2. Radiographic absorptiometry (RA)
3. Bone sonometry (ultrasound)
4. Single energy x-ray absorptiometry (SEXA)
5. Quantitative computed tomography (QCT)
Earlier technologies, such as single and dual photon absorptiometry (CPT codes 78350 or 78351) are no longer used.
Indications
A. Medicare covers a bone mass measurement (BMM) for a beneficiary once every two years (if at least 23 months have past since the month the last bone mass measurement was performed). The criteria for bone mass measurement every two years are listed below;
1. It is performed with a bone densitometer, other than dual photon absorptiometry (DPA) or a bone sonometer (e.g., ultrasound) device that has been approved or cleared for marketing by the Food and Drug Administration (FDA).
2. It is performed on a qualified individual for the purpose of identifying bone mass, detecting bone loss or determining bone quality. The term "qualified individual" means an individual who meets the medical indications for at least one of the criteria listed below:
a. A woman who has been determined by the physician or a qualified non-physician treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other indicators.
b. An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral fracture.
c. An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to 5 mg of prednisone, or greater, per day for more than three months.
d. An individual with primary hyperparathyroidism,
e. An individual being monitored to assess the response to or efficacy of an FDA approved osteoporosis drug therapy.
3. If it is furnished by a qualified supplier or provider of such services, under at least the general level of supervision of a physician as defined in section 1861 of the Social Security Act.
4. If the test is ordered by the individual's physician or qualified non- physician practitioner, who is treating the beneficiary following an evaluation of the need for the measurement, including a determination as to the medically appropriate measurement to be used for the individual, and who uses the results in the management of the patient.
5. The test is reasonable and necessary for diagnosing, treating or monitoring of a "qualified" individual as defined above.
B. For conditions specified below, Medicare will cover a bone mass measurement for a qualified beneficiary more frequently than every two years, if medically necessary for the diagnosis or treatment of the patient and if related to the condition listed. To be considered at least eleven months must have elapsed since the previous bone mass measurement test. Such conditions are;
1. Monitoring beneficiaries on long-term glucocorticoid (steroid) therapy, equal to 5 mg of prednisone or greater, for more than three months. (Patients must be on glucocorticoids for greater than three months duration, but BMM monitoring is at yearly intervals).
2. Confirming baseline BMMs to permit monitoring of beneficiaries in the future. (CMS Publication 100-02, Ch. 15, §80.5.5).
In addition, bone mass measurement for the following may be reimbursed more frequently than every two years:
3. Follow up bone mineral density testing to assess FDA-approved osteoporosis drug therapy until a response to such therapy has been documented over time.
C. Medicare will cover a confirmatory baseline bone mass measurement when it is performed with a dual energy x-ray absorptionmetry system (axial skeletal) to permit monitoring of beneficiaries in the future, if the initial test was performed with a technique that is different from the proposed monitoring method (for example, if the initial test was bone sonometry and the patient will be monitored with bone densitometry, a second test utilizing densitometry will be paid). If the initial bone mass measurement was performed by a dual-energy x-ray absorptionmetry system (axial skeletal), than a confirmatory BMM is not covered.
D. There are multiple techniques for obtaining bone mass or bone density information. There is a difference in the precision, and accuracy of the different techniques and the sensitivity of measurement in axial (central) or peripheral sites. In general, because cancellous bone changes more rapidly in time and with therapeutic intervention, the sites of cancellous bone (lumbar spine, proximal femur) are more likely than peripheral sites or cortical bone to show a response to FDA approved osteoporosis drug therapy and are preferred for baseline and drug monitoring purposes. The most reliable comparative results for drug monitoring are obtained when the same BMM instrument is used. Based on this, Medicare coverage is limited to those techniques which have been rated favorably in clinical studies.
Coding Information
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.
| 012x | Hospital Inpatient (Medicare Part B only) |
| 013x | Hospital Outpatient |
| 022x | Skilled Nursing - Inpatient (Medicare Part B only) |
| 023x | Skilled Nursing - Outpatient |
| 034x | Home Health - Other (for medical and surgical services not under a plan of treatment) |
| 071x | Clinic - Rural Health |
| 072x | Clinic - Hospital Based or Independent Renal Dialysis Center |
| 073x | Clinic - Freestanding |
| 085x | Critical Access Hospital |
Revenue Codes:
Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.
Revenue codes 096X, 097X and 098X are to be used only by Critical Access Hospitals (CAHs) choosing the optional payment method (also called Option 2 or Method 2) and only for services performed by physicians or practitioners who have reassigned their billing rights. When a CAH has selected the optional payment method, physicians or other practitioners providing professional services at the CAH may elect to bill their carrier or assign their billing rights to the CAH. When professional services are reassigned to the CAH, the CAH must bill the FI using revenue codes 096X, 097X or 098X.
Note: Any explanatory text for this field now allows comments.
CPT/HCPCS 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.
Revenue codes only apply to providers who bill these services to the fiscal intermediary. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier.Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.
Revenue codes 096X, 097X and 098X are to be used only by Critical Access Hospitals (CAHs) choosing the optional payment method (also called Option 2 or Method 2) and only for services performed by physicians or practitioners who have reassigned their billing rights. When a CAH has selected the optional payment method, physicians or other practitioners providing professional services at the CAH may elect to bill their carrier or assign their billing rights to the CAH. When professional services are reassigned to the CAH, the CAH must bill the FI using revenue codes 096X, 097X or 098X.
Note: Any explanatory text for this field now allows comments.
| 0320 | Radiology - Diagnostic - General Classification |
| 0333 | Radiology - Therapeutic and/or Chemotherapy Administration - Radiation Therapy |
| 034X | Nuclear Medicine - General Classification |
| 035X | CT Scan - General Classification |
| 040X | Other Imaging Services - General Classification |
| 052X | Free-Standing Clinic - General Classification |
| 061X | Magnetic Resonance Technology (MRT) - General Classification |
| 0960 | Professional Fees - General Classification |
| 0969 | Professional Fees - Other Professional Fee |
| 0972 | Professional Fees - Radiology - Diagnostic |
| 0982 | Professional Fees - Outpatient Services |
| 0983 | Professional Fees - Clinic |
Note: CPT codes 78350 and 78351 are non-covered procedures under Medicare
| 76977 | ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETATION, PERIPHERAL SITE(S), ANY METHOD |
| 77078 | COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE) |
| 77080 | DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE) |
| 77081 | DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; APPENDICULAR SKELETON (PERIPHERAL) (EG, RADIUS, WRIST, HEEL) |
| 78350 | BONE DENSITY (BONE MINERAL CONTENT) STUDY, 1 OR MORE SITES; SINGLE PHOTON ABSORPTIOMETRY |
| 78351 | BONE DENSITY (BONE MINERAL CONTENT) STUDY, 1 OR MORE SITES; DUAL PHOTON ABSORPTIOMETRY, 1 OR MORE SITES |
| G0130 | SINGLE ENERGY X-RAY ABSORPTIOMETRY (SEXA) BONE DENSITY STUDY, ONE OR MORE SITES; APPENDICULAR SKELETON (PERIPHERAL) (EG, RADIUS, WRIST, HEEL) |
ICD-9 Codes that Support Medical Necessity
When 77078, 77081, 76977 or G0130 is done as an initial diagnostic test that determines a diagnosis of 255.0, 733.00, 733.01, 733.02, 733.03, 733.09 or 733.90, code as a secondary diagnosis the reason for the bone mass density test.
Patients who qualify by statute for osteoporosis screening may be evaluated by studies that are characterized by CPT codes 77078, 77079, 77080, 77081, 76977, and G0130. The following is a list of ICD-9-CM codes that support the medical necessity of osteoporosis screening
For Use with CPT Codes 77078, 77080, 77081, 76977, G0130
| 242.00 | TOXIC DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM |
| 242.01 | TOXIC DIFFUSE GOITER WITH THYROTOXIC CRISIS OR STORM |
| 242.10 - 242.11 | TOXIC UNINODULAR GOITER WITHOUT THYROTOXIC CRISIS OR STORM - TOXIC UNINODULAR GOITER WITH THYROTOXIC CRISIS OR STORM |
| 242.20 - 242.21 | TOXIC MULTINODULAR GOITER WITHOUT THYROTOXIC CRISIS OR STORM - TOXIC MULTINODULAR GOITER WITH THYROTOXIC CRISIS OR STORM |
| 242.30 - 242.31 | TOXIC NODULAR GOITER UNSPECIFIED TYPE WITHOUT THYROTOXIC CRISIS OR STORM - TOXIC NODULAR GOITER UNSPECIFIED TYPE WITH THYROTOXIC CRISIS OR STORM |
| 242.40 - 242.41 | THYROTOXICOSIS FROM ECTOPIC THYROID NODULE WITHOUT THYROTOXIC CRISIS OR STORM - THYROTOXICOSIS FROM ECTOPIC THYROID NODULE WITH THYROTOXIC CRISIS OR STORM |
| 242.80 - 242.81 | THYROTOXICOSIS OF OTHER SPECIFIED ORIGIN WITHOUT THYROTOXIC CRISIS OR STORM - THYROTOXICOSIS OF OTHER SPECIFIED ORIGIN WITH THYROTOXIC CRISIS OR STORM |
| 242.90 - 242.91 | THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE AND WITHOUT THYROTOXIC CRISIS OR STORM - THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE WITH THYROTOXIC CRISIS OR STORM |
| 246.0 | DISORDERS OF THYROCALCITONIN SECRETION |
| 252.00 - 252.02 | HYPERPARATHYROIDISM, UNSPECIFIED - SECONDARY HYPERPARATHYROIDISM, NON-RENAL |
| 252.08 | OTHER HYPERPARATHYROIDISM |
| 253.2 | PANHYPOPITUITARISM |
| 256.2 | POSTABLATIVE OVARIAN FAILURE |
| 256.31 | PREMATURE MENOPAUSE |
| 256.39 | OTHER OVARIAN FAILURE |
| 257.2 | OTHER TESTICULAR HYPOFUNCTION |
| 259.3 | ECTOPIC HORMONE SECRETION NOT ELSEWHERE CLASSIFIED |
| 262 | OTHER SEVERE PROTEIN-CALORIE MALNUTRITION |
| 263.0 - 263.9 | MALNUTRITION OF MODERATE DEGREE - UNSPECIFIED PROTEIN-CALORIE MALNUTRITION |
| 268.2 | OSTEOMALACIA UNSPECIFIED |
| 268.9 | UNSPECIFIED VITAMIN D DEFICIENCY |
| 275.40 - 275.49 | UNSPECIFIED DISORDER OF CALCIUM METABOLISM - OTHER DISORDERS OF CALCIUM METABOLISM |
| 555.0 - 555.9 | REGIONAL ENTERITIS OF SMALL INTESTINE - REGIONAL ENTERITIS OF UNSPECIFIED SITE |
| 556.0 - 556.9 | ULCERATIVE (CHRONIC) ENTEROCOLITIS - ULCERATIVE COLITIS UNSPECIFIED |
| 579.0 - 579.9 | CELIAC DISEASE - UNSPECIFIED INTESTINAL MALABSORPTION |
| 585.1 - 585.9 | CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE, UNSPECIFIED |
| 588.0 | RENAL OSTEODYSTROPHY |
| 588.81 | SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN) |
| 588.89 | OTHER SPECIFIED DISORDERS RESULTING FROM IMPAIRED RENAL FUNCTION |
| 626.0 | ABSENCE OF MENSTRUATION |
| 627.0 - 627.9 | PREMENOPAUSAL MENORRHAGIA - UNSPECIFIED MENOPAUSAL AND POSTMENOPAUSAL DISORDER |
| 731.0 | OSTEITIS DEFORMANS WITHOUT BONE TUMOR |
| 733.10 - 733.19 | PATHOLOGICAL FRACTURE UNSPECIFIED SITE - PATHOLOGICAL FRACTURE OF OTHER SPECIFIED SITE |
| 733.93 - 733.95 | STRESS FRACTURE OF TIBIA OR FIBULA - STRESS FRACTURE OF OTHER BONE |
| 737.10 | KYPHOSIS (ACQUIRED) (POSTURAL) |
| 753.12 - 753.19 | POLYCYSTIC KIDNEY UNSPECIFIED TYPE - OTHER SPECIFIED CYSTIC KIDNEY DISEASE |
| 758.6 | GONADAL DYSGENESIS |
| 781.91 | LOSS OF HEIGHT |
| 805.00 - 805.08 | CLOSED FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL - CLOSED FRACTURE OF MULTIPLE CERVICAL VERTEBRAE |
| 805.10 - 805.9 | OPEN FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL - OPEN FRACTURE OF UNSPECIFIED PART OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY |
| 806.00 - 806.09 | CLOSED FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY |
| 806.10 - 806.19 | OPEN FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY |
| 806.20 - 806.29 | CLOSED FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY |
| 806.30 - 806.39 | OPEN FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY |
| 806.4 | CLOSED FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY |
| 806.5 | OPEN FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY |
| 806.60 - 806.69 | CLOSED FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY |
| 806.70 - 806.9 | OPEN FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY |
| 820.00 - 820.9 | FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK OF FEMUR CLOSED - FRACTURE OF UNSPECIFIED PART OF NECK OF FEMUR OPEN |
| 962.0 | POISONING BY ADRENAL CORTICAL STEROIDS |
| 995.20 | UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE |
| V45.77 | ACQUIRED ABSENCE OF ORGAN GENITAL ORGANS |
| V49.81 | ASYMPTOMATIC POSTMENOPAUSAL STATUS (AGE-RELATED) (NATURAL) |
| V50.42 | PROPHYLACTIC OVARY REMOVAL |
| V58.65 | LONG-TERM (CURRENT) USE OF STEROIDS |
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).
V58.65, V58.68 and/or V67.51, when used to monitor effectiveness of drug treatment, require a primary ICD-9 -CM diagnosis code from the list directly below.
| 255.0 | CUSHING'S SYNDROME |
| 733.00 | OSTEOPOROSIS UNSPECIFIED |
| 733.01 | SENILE OSTEOPOROSIS |
| 733.02 | IDIOPATHIC OSTEOPOROSIS |
| 733.03 | DISUSE OSTEOPOROSIS |
| 733.09 | OTHER OSTEOPOROSIS |
| 733.90 | DISORDER OF BONE AND CARTILAGE UNSPECIFIED |
| V58.65 | LONG-TERM (CURRENT) USE OF STEROIDS |
| V58.68 | LONG TERM (CURRENT) USE OF BISPHOSPHONATES |
| V67.51 | FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED |
Diagnoses that Support Medical Necessity
Diagnoses listed above
ICD-9 Codes that DO NOT Support Medical Necessity
ICD-9 Codes not listed above
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Diagnoses not listed above
General Information
1. Physicians'
Services and diagnostic tests must be submitted with an ICD-9 code to
support the medical necessity for the service and must be coded to the
greatest level of accuracy and highest level of digit completeness.
This means the precise ICD-9 code that fully explains the narrative
description of the diagnosis contained in the medical record or the test
interpretation and report including the 4th or 5th digit
sub-classification for the diagnosis category. The ICD-9 code based on
the results of the test should be the primary diagnosis. If the
diagnostic test results are normal or inconclusive the ICD-9 code
representing the sign, symptom, illness or injury prompting the ordering
of the test should be reported as the primary diagnosis.
2. Medical records should be legible, contain the relevant history, physical findings conforming to the criteria stated in the "Indications and Limitation of Coverage/Medical Necessity" section of this policy and must be made available to the Carrier on request. This documentation (medical records/history or and x-ray report) must be available for submission with the original and all subsequent claims upon request
3. Documentation supporting medical necessity including the reason for testing, the method used, and the site(s) evaluated, plus a test report should be in the patient's record.
4. The patient's medical record must document that patient meets one of the requirements of a "qualified individual" as described in the Indications and Limitations of Coverage section of this policy.
5. Documentation supporting medical necessity must be indicated in the narrative field and available upon request
6. ICD-9-CM code V45.77 should be reported for women s/p oophorectomy.
7. ICD-9-CM code V58.65 should be reported for an individual on glucocorticoid therapy.
8. ICD-9-CM code V58.68 should be reported for DXA testing while taking medicines for osteoporosis/osteopenia.
9. ICD-9-CM code V67.51 should be reported for an individual who has COMPLETED drug therapy for osteoporosis and is being monitored for response to therapy.
2. Medical records should be legible, contain the relevant history, physical findings conforming to the criteria stated in the "Indications and Limitation of Coverage/Medical Necessity" section of this policy and must be made available to the Carrier on request. This documentation (medical records/history or and x-ray report) must be available for submission with the original and all subsequent claims upon request
3. Documentation supporting medical necessity including the reason for testing, the method used, and the site(s) evaluated, plus a test report should be in the patient's record.
4. The patient's medical record must document that patient meets one of the requirements of a "qualified individual" as described in the Indications and Limitations of Coverage section of this policy.
5. Documentation supporting medical necessity must be indicated in the narrative field and available upon request
6. ICD-9-CM code V45.77 should be reported for women s/p oophorectomy.
7. ICD-9-CM code V58.65 should be reported for an individual on glucocorticoid therapy.
8. ICD-9-CM code V58.68 should be reported for DXA testing while taking medicines for osteoporosis/osteopenia.
9. ICD-9-CM code V67.51 should be reported for an individual who has COMPLETED drug therapy for osteoporosis and is being monitored for response to therapy.
Appendices
Utilization Guidelines
Refer to Indications
and Limitations of Coverage and/or Medical Necessity sections of this
LCD.
1. Medicare reimbursement for an initial bone mass measurement may be allowed only once, regardless of sites studied (e.g., if the spine and hip are studied, CPT code 77080 should be billed only once).
2. It is not medically necessary to perform more than one type of BMM test in any individual, unless a DXA confirmatory test is performed as a baseline for future monitoring. (See paragraph C in Indications and Limitations of Coverage section).
3. It is normally not medically necessary to have both peripheral and axial BMM tests performed. In the rare instance of an indeterminate confirmatory diagnosis, upon appeal documentation submitted will be evaluated for possible payment.
4. Medicare will not reimburse BMM tests performed by a second provider, when a test has already been performed within the defined coverage period.
1. Medicare reimbursement for an initial bone mass measurement may be allowed only once, regardless of sites studied (e.g., if the spine and hip are studied, CPT code 77080 should be billed only once).
2. It is not medically necessary to perform more than one type of BMM test in any individual, unless a DXA confirmatory test is performed as a baseline for future monitoring. (See paragraph C in Indications and Limitations of Coverage section).
3. It is normally not medically necessary to have both peripheral and axial BMM tests performed. In the rare instance of an indeterminate confirmatory diagnosis, upon appeal documentation submitted will be evaluated for possible payment.
4. Medicare will not reimburse BMM tests performed by a second provider, when a test has already been performed within the defined coverage period.
Sources of Information and Basis for Decision
American College of
Radiology, ACR Appropriateness CriteriaTM - Osteoporosis and bone mineral
density (2001 and 2010 revised)
2. DEXA National Workgroup Memo, American Association of Clinical Endocrinologists - Osteoporosis Clinical Practice Guidelines (2001).
3. Institute for Clinical System Improvement, Health Care Guidelines: Diagnosis and Treatment of Osteoporosis (July 2002)
4. National Osteoporosis Foundation - Physicians Guide to Prevention and Treatment of Osteoporosis 2000, Update on Medication (2002)
5. The International Society for Clinical Densitometry (2007); Official position of the International Society for Clinical Densitometry. Retrieved from the internet 05/25/2011 at
http://www.ISCD.org
6. The U.S. Preventive Services Task Force (USPSTF) Recommendation: Screening for Osteoporosis in Postmenopausal Women (September 2002)
2. DEXA National Workgroup Memo, American Association of Clinical Endocrinologists - Osteoporosis Clinical Practice Guidelines (2001).
3. Institute for Clinical System Improvement, Health Care Guidelines: Diagnosis and Treatment of Osteoporosis (July 2002)
4. National Osteoporosis Foundation - Physicians Guide to Prevention and Treatment of Osteoporosis 2000, Update on Medication (2002)
5. The International Society for Clinical Densitometry (2007); Official position of the International Society for Clinical Densitometry. Retrieved from the internet 05/25/2011 at
http://www.ISCD.org
6. The U.S. Preventive Services Task Force (USPSTF) Recommendation: Screening for Osteoporosis in Postmenopausal Women (September 2002)
Advisory Committee Meeting Notes
Wisconsin 01/28/2011
Illinois 01/26/2011
Michigan 02/02/2011
Minnesota 01/20/2011
Iowa, Kansas,
Missouri, Nebraska 02/10/2011
This LCD consolidates and replaces all previous policies and publications on this topic by the carrier and fiscal intermediary predecessors of Wisconsin Physician Services.
For claims submitted to the fiscal intermediary; This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated Wisconsin Physician Services (formerly Mutual of Omaha) to process their claims
Italicized lettering indicates CMS wording
* An asterisk indicates most recent publishing or revision
This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with the Carrier Advisory Committee, which included representatives from various medical specialties.
NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.
Illinois 01/26/2011
Michigan 02/02/2011
Minnesota 01/20/2011
Iowa, Kansas,
Missouri, Nebraska 02/10/2011
This LCD consolidates and replaces all previous policies and publications on this topic by the carrier and fiscal intermediary predecessors of Wisconsin Physician Services.
For claims submitted to the fiscal intermediary; This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated Wisconsin Physician Services (formerly Mutual of Omaha) to process their claims
Italicized lettering indicates CMS wording
* An asterisk indicates most recent publishing or revision
This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with the Carrier Advisory Committee, which included representatives from various medical specialties.
NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.
Start Date of Comment Period
02/10/2011
End Date of Comment Period
03/27/2011
Start Date of Notice Period
07/01/2011
Revision History Number
X
Revision History Explanation
02/21/2011 - In
accordance with Section 911 of the Medicare Modernization Act of 2003,
the states of Delaware, District of Columbia, Maryland, New Jersey and
Pennsylvania were removed from this LCD because claims processing for
these states are transitioning from FI Wisconsin Physician Service (WPS
52280) to MAC Part A contractor Highmark (12901).
07/01/2011 - Draft policy being released to Final.
10/12/2011: Deleted ICD-9-CM code V58.69 and replaced all references to it with ICD-9-CM new for 2012 code V58.68, which is specific for long term (current) use of bisphosphonates. Added the second sentence to statement number three (3) found in the Utilization Guidelines. Sentence number (3) now states;
It is normally not medically necessary to have both peripheral and axial BMM tests performed. In the rare instance of an indeterminate confirmatory diagnosis, upon appeal documentation submitted will be evaluated for possible payment.
Effective 10/01/2011 (one).
11/21/2011 - The following CPT/HCPCS codes were deleted:
77079 was deleted from Group 1
77083 was deleted from Group 1
01/01/2012: 2012 CPT update; Discontinued CPT code 77079 (two).
04/01/2012: CPT 2012 coding update discontinued CPT code 77083. Effective 01/01/2012 (three).
07/01/2011 - Draft policy being released to Final.
10/12/2011: Deleted ICD-9-CM code V58.69 and replaced all references to it with ICD-9-CM new for 2012 code V58.68, which is specific for long term (current) use of bisphosphonates. Added the second sentence to statement number three (3) found in the Utilization Guidelines. Sentence number (3) now states;
It is normally not medically necessary to have both peripheral and axial BMM tests performed. In the rare instance of an indeterminate confirmatory diagnosis, upon appeal documentation submitted will be evaluated for possible payment.
Effective 10/01/2011 (one).
11/21/2011 - The following CPT/HCPCS codes were deleted:
77079 was deleted from Group 1
77083 was deleted from Group 1
01/01/2012: 2012 CPT update; Discontinued CPT code 77079 (two).
04/01/2012: CPT 2012 coding update discontinued CPT code 77083. Effective 01/01/2012 (three).
Reason for Change
HCPCS Addition/Deletion
Related Documents
This LCD has no Related Documents.
LCD Attachments
Coding & Billing Guidelines 4/1/12 (PDF - 27 KB)
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Page Last Updated: Tuesday, 03-Apr-2012 09:21:40 CDT
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