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.
- 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.
- 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.
- 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.
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
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
|
733.00–733.03
|
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
|
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
|
- 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.
- 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.
- Untreated patients with osteoporosis who refuse therapy and require close monitoring because of high risk for further bone loss.
733.00–733.03
|
Osteoporosis
|
733.09
|
Other osteoporosis
|
V58.65
|
Long-term (current) use of steroids
|
- 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.
- 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.