Bone Mass Measurement (BMM) cpt – 76977, 77080, 77078, 77081, g0130 and valid DX

Bone Mass Measurements HCPCS/CPT Codes

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 (e.g., hips, pelvis, spine)

77080 – Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis,
spine)

77081 – DXA, bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

G0130 – Single energy X-ray absorptiometry (SEXA) bone density study, 1 or more sites, appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

Who Is Covered

Certain Medicare beneficiaries who fall into at least one of the following categories:

* Women determined by their physician or qualified non-physician practitioner (NPP) to be estrogen deficient and at clinical risk for osteoporosis

* Individuals with vertebral abnormalities

* Individuals getting (or expecting to get) glucocorticoid therapy for more than 3 months

* Individuals with primary hyperparathyroidism

* Individuals being monitored to assess response to U.S. Food and Drug Administration (FDA)-approved osteoporosis drug therapy Frequency

* Every 2 years

* More frequently if medically necessary Medicare Beneficiary Pays

* Copayment/coinsurance waived

* Deductible waived

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:

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:

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.

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:

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:

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:

Medicare is establishing the following limited coverage for CPT/HCPCS codes 76977, 77078, 77079, 77081, 77083and G0130:

Covered for:

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:

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:

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.

In these three situations, one of the following ICD-9-CM diagnosis codes must be used:

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

3) Billing Multiple Studies on the Same Date of Service

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.