Limitations for bone mass measurement

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Limitations for bone mass measurement (BMM)

  1. Tests not ordered by the physician/qualified non-physician practitioner, who is treating the individual, are not reasonable and necessary.
  2. Oxford’s 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).
  3. 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 Indications #7 and #8).
  4. It is not medically necessary to have both peripheral and axial BMM tests performed on the same day.
  5. Oxford will not reimburse BMM tests performed by a second provider, when a test has already been performed within the defined coverage period, as stated above, unless as confirmatory testing for future monitoring. Individuals must authorize providers to obtain prior test results. If unsuccessful efforts to obtain prior test results from another provider are documented, new tests may be considered for reimbursement.
  6. Single and dual photon absorptiometry, CPT code 78350 and 78351, are non-covered services.
  7. Bone mass measurement is not covered and will be denied when performed by a portable x-ray supplier. Transportation charges for BMM testing will be denied
  8. Bone mass measurement tests provided without an accompanying interpretation and report, as part of the test, will be denied as not medically necessary.
  10. Bone mass measurement tests will be denied as not medically necessary if performed by a non-physician practitioner. 
  12. CPT code 77082 is considered by Medicare to represent vertebral fracture assessment only. Because code 77082 does not represent a bone density study, it should NOT be billed for screening. This code may be billed when medically necessary (i.e. when a vertebral fracture assessment is required). Symptoms should be present and documented, and it should be anticipated that the results of the test will be used in the management of the patient.