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Medical Coding News Archives

Bone Mass Measurement Tests Are Inappropriately Denied

 
March 11, 2008:
Certain covered bone mass measurement (BMM) tests are being denied in error, despite an established national coverage determination. In response, the Centers for Medicare and Medicaid Services has issued a transmittal clarifying the claims processing instructions for BMM tests.

Bone density testing is one of only 12 preventive services currently covered by Medicare. Bone mass measurements are used to evaluate diseases of the bone, assess bone mass or density associated with such diseases as osteoporosis. The terms “bone mass measurement” or “bone density study,” are radiological or radioisotope procedure performed to measure bone mass, detect bone loss, and determine bone quality.

CMS’ national coverage determination for bone density testing procedures specifies the type of procedures covered, eligibility requirements, frequency limitations, and other provider requirements. In 2007, CMS issued change request (CR) 5521, which addresses coverage policy and claims processing instructions for BMM tests. Even so, some covered services have been denied in error; specifically, BMM procedure codes 76977, 77078, 77079, 77081, 77083, and G0130 have been denied when the claim includes both a screening diagnosis code and an osteoporosis code.

CMS has now issued Transmittal 1416, CR 5847, confirming that Medicare contractors will pay claims for screening tests when coded as follows:
  • CPT®/HCPCS procedure code 77078, 77079, 77080, 77081, 77083, 76977, or G0130
  • A valid ICD-9-CM diagnosis code indicating the reason for the test as postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy
HCPCS/CPT® procedure codes:
77078 Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)
77079 Computed tomography, bone mineral density study, 1 or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)
77081 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
77083 Radiographic absorptiometry (e.g., photodensitometry, radiogrammetry), 1 or more sites
76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method
G0130 Single energy x-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

Medicare will pay claims for monitoring tests when coded as follows:
  • CPT® procedure code 77080
  • ICD-9-CM diagnosis code 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0:
    733.00 - Unspecified osteoporosis
    733.01 - Senile osteoporosis
    733.02 - Idiopathic osteoporosis
    733.03 - Disuse osteoporosis
    733.09 - Other osteoporosis
    733.90 - Disorder of bone and cartilage, unspecified
    255.0 - Cushing's syndrome
For eligible individuals, Medicare will pay for a bone density study once every two years. Eligibility requirements include:
  • Estrogen-deficiency or at clinical risk for osteoporosis
  • Vertebral abnormalities indicating osteoporosis, osteopenia, or vertebral fracture
  • Screening categories indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.
Certain medically necessary conditions are exceptions to the frequency limitation, including long-term steroid therapy (e.g., glucocorticoid therapy for more than 3 months), hyperparathyroidism, or when performed as monitoring to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy.
  • Claims for services rendered to patients receiving glucocorticoid therapy for more than three months, ICD-9-CM code V58.69 (long-term [current] use of steroids)
  • Claims for patients being treated with an FDA-approved osteoporosis drug should be coded with ICD-9-CM code V67.59 [follow-up examination following other treatment]
For example, according to the AHA Coding Clinic diagnosis coding guidelines for encounters for osteoporosis screening (fourth quarter 2000), an asymptomatic, postmenopausal patient who presents for a bone density study to evaluate for osteoporosis should be coded as follows:
V82.81 Special screening for osteoporosis
V49.81 Postmenopausal status, may be used as an additional diagnosis

Medicare contractors will continue to deny bone mass measurement claims that do not contain a valid ICD-9-CM diagnosis code indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.

Conditions for coverage of bone mass measurements are now contained in chapter 15, section 80.5 of Pub.100-02, Medicare Benefit Policy Manual. Claims processing instructions can be found in chapter 13, section 140 of Pub. 100-04, Medicare Claims Processing Manual.

Providers should be aware that Medicare contractors will not search for claims already processed, but they are required to adjust any inappropriately denied claims that are brought to their attention.

Sarah A. Serling, CPC, CPC-H, CPC-I, CCS-P, CCS
Clinical Technical Editor

 

 
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