Friday, October 22, 2010

Bone DENSITY/ DEXA/ CAT SCAN CPT code 77080, 77081, 74170 AND LIST

RADIOLOGY PROCEDURE CODE EASY GUIDE FOR BONE DENSITY/DEXA/CAT SCAN


BONE DENSITOMETRY/DEXA

DEXA – hips, spine. . . . . . . . . . . . . . . . . . . . . . 77080
P-DEXA forearm . . . . . . . . . . . . . . . . . . . . . . . 77081

CAT SCAN

ABDOMEN

Abdomen w/o contrast . . . . . . . . . . . . . .. . . . 74150
Abdomen w/ contrast . . . . . . . . . . . . . . .. . . . 74160
Abdomen w/o & w/ contrast. . . . . . . . . . .. . . 74170

CHEST/THORAX

Chest/Thorax w/o contrast . . . . . . . . . . .. . . .71250
Chest/Thorax w/ contrast. . . . . . . . . . . .. . . . 74150
Chest/Thorax w/o & w/ contrast . . . . . .. . . . 71270

EXTREMITIES

Upper w/o contrast . . . . . . . . . . . . . . . . . . . . . 73200
Upper w/o & w/ contrast. . . . . . . . . . . . . . . . . 73202
Lower w/o contrast . . . . . . . . . . . . . . . . . . . . . 73700
Lower w/o & w/ contrast. . . . . . . . . . . . . . . . . 73702




Procedure 74170 CT abdomen without and with contrast 


DEXA BONE DENSITY SCAN

Medicare will cover DEXA bone mass measurement once every 2 years on a person who falls into 1 out of the 5 Following categories:

1. A woman who has been determined by her physician to be estrogen-deficient and at clinical risk for osteoporosis.

2. An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia,
or vertebral fracture.

3. An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy.

4. An individual with primary hyperparathyroidism.

5. If an individual is currently taking one of the following FDA approved Osteoporosis Medications:

•Fosamax, Actonel, Miacalcin, Evista, Forteo

* Estrogen Estrogen Therapy Therapy and Hormone Hormone Therapy Therapy are also approved approved for the treatment treatment of osteoporosis osteoporosis in post-menopausal menopausal women.

*The list of glucosteroids is far too extensive to include, but these are also approved. Check the brand name on the web
for confirmation.

Any of the above reasons must be documented in the order.  If it is not, this will be considered by Medicare to be not medically necessary and Arcadia Radiology will require the patient to sign an ABN form.


Palmetto GBA Jurisdiction 1 Part B Guidelines

Bone Mass Measurement (BMM) is covered by Medicare under the following conditions:

– Ordered by the physician or qualified non-physician practitioner who is treating the beneficiary and uses the results in the management of the patient

– Is performed under the appropriate physician supervision as defined in 42 CFR 410.32(b)

– Is reasonable and necessary for diagnosing and treating the beneficiary's condition

– For an individual individual being monitored monitored to assess the response response or efficacy efficacy of an FDA approved approved osteoporosis osteoporosis drug therapy therapy, is performed performed with a dual energy X-ray absorptiometry system (axial skeleton) (77080)

– In an individual who has a confirmatory BMM that is performed by a dual-energy X-ray absorptiometry system (axial system) if the initial BMM was not performed by a dual-energy X-ray absorptiometry system (axial skeleton). A confirmatory baseline BMM is not covered if the BMM was performed by a dual-energy X-ray absorptiometry system (axial skeleton).

– Monitoring after a diagnosis of osteoporosis has been established the following ICD-9 codes that should be submitted with Procedure code 77080: 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, 255.0.

– Medicare pays for a screening BMM once every two years (at least 23 months have passed since the month the last covered BMM was covered).

– A BMM is covered if the beneficiary meets at least one of the following conditions:

– The woman has been d d etermined by the physician or qualf d i ie nonphysician practitioner treating her to be estrogen-d f e icient and at cl l inica risk for osteoporosis, based on her medical history and other findings

– An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia or vertebral fracture

– An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg 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 an FDA-approved osteoporosis drug therapy



Billing and Coding Guidelines

Effective for dates of service on or after January 1, 2007, Medicare will pay for  MM services for dual-energy x-ray absorptiometry (Procedure code 77080) when this procedure is used to monitor osteoporosis drug therapy. In addition, new Procedure code were assigned to BMMs.

• Effective for dates of service on and after January 1, 2007, the CY 2007 Physician Fee Schedule final rule expanded the number of beneficiaries qualifying for BMM by reducing the dosage requirement for glucocorticoid (steroid) therapy from 7.5 mg of prednisone per day to 5.0 mg. It also  changed the definition of BMM by removing coverage for a single-photon absorptiometry (SPA) as it is not considered reasonable and necessary under section 1862 (a)(1)(A) of the Act.

• Effective for dates of services on and after January 1, 2007, the following changes apply to BMM:

• New 2007 Procedure  code bone mass codes have been assigned for BMM. The following codes will replace current codes, however the Procedure code descriptors for the services remain the same:

77078 replaces 76070 77081 replaces 76076

77079 replaces 76071 77083 replaces 76078

77080 replaces 76075



BMM is covered when dual-energy x-ray absorptiometry is used to monitor osteoporosis drug therapy. Therefore, Medicare will pay procedure code 77080 when billed with the following ICD-9-CM diagnosis codes or any of the other valid ICD-9-CM diagnoses that are recognized by Medicare contractors appropriate for bone mass measurements:

733.00 733.01 733.02 733.03 733.09 733.90 255.0


Effective for dates of service on or after January 1, 2007, Medicare will pay for BMM services for dual-energy x-ray absorptiometry (Procedure code 77080) when this procedure is used to monitor osteoporosis drug therapy. New Procedure  codes have also been assigned to BMMs.

In Connecticut, using this code and other available information Payer E has a denial rate of 33% in the last 12 months, while Payer A, Payer B, and Payer D all have denial rates below 5%. This causes the denial rate for Payer E to be 6 times higher, a rate based on information from a selection of Connecticut physicians during this time period.

This example highlights the variation in insurers’ interpretation of medical necessity in the context of this diagnostic study. If a patient had a particular need for the nature of this procedure due to their personal and family history of bone mass loss, this data in combination with other information would support the patient’s ability to make an informed decision.

Under ICD-9-CM, the term “Osteopenia” was indexed to ICD-9-CM diagnosis code 733.90 (Disorder of bone and cartilage). This code was listed as a covered condition under the Business requirement 5521.1.1 for CR 5521/NCD 150.3, dated May 11, 2007, when reported with Procedure code 77080. (See related MLN Matters article MM5521.) The accompanying Benefit Policy Manual,
Publication 100-02, chapter 15, section 80.5.6, Beneficiaries Who May Be Covered, includes: 2. An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture.


Policy

BCBSNC will provide coverage for Axial (Central) Bone Mineral Density (BMD) Studies when they are determined to be medically necessary because the medical criteria and guidelines shown below  are met.

Benefits Application

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design;

therefore member benefit language should be reviewed before applying the terms of this medical policy.

When Bone Mineral Density Studies are covered

Initial or repeat bone mineral density (BMD) measurement is not indicated unless the results will influence treatment decisions.

An initial measurement of BMD at the hip or spine may be considered medically necessary to assess fracture risk and the need for pharmacologic therapy in both women and men who are considered at risk for osteoporosis. BMD testing may be indicated under the following conditions:

* Women age 65 and older, regardless of other risk factors;

* Men age 70 and older, regardless of other risk factors;

* Younger postmenopausal women about whom there is a concern based on their risk factors;

* Men age 50-70 about whom there is a concern based on their risk factors;

* Adults with a condition or taking a medication associated with low bone mass or bone loss.

Repeat measurement of central (hip/spine) BMD for individuals who previously tested normal (does not require pharmacologic treatment) may be considered medically necessary at an interval not more frequent than every 3–5 years; the interval depends on patient risk factors.

Regular (not more frequent than every 2–3 years) serial measurements of central BMD to monitor  treatment response may be considered medically necessary when the information will affect treatment decisions such as duration of therapy.

Peripheral measurement of BMD may be considered medically necessary:


* If the hip/spine or hip/hip cannot be done or the patient is over the table limit for weight;

* For hyperparathyroidism, where the forearm is essential for diagnosis

When Bone Mineral Density Studies are not covered Bone mineral density studies are considered not medically necessary if the criteria listed above are not met.

Screening individuals who are at low risk for osteoporosis is considered not medically necessary.

Ultrasound technology to measure and interpret bone density at peripheral sites by any method is considered investigational.

Peripheral or appendicular bone density studies are considered not medically necessary except as noted above.

Dual x-ray absorptiometry (DXA) body composition studies are considered investigational.


Limitations:

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, Procedure code 77080 should be billed only once).

77080 DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE)


ICD-9-CM code 733.90 should be reported to indicate osteopenia, (only when billing 77080-DXA), when used to follow treatment with FDA approved osteoporosis medications.


Procedure coding:

Procedure code 77082 is considered by Medicare to represent vertebral fracture assessment only. Because code 77082 does not represent a BONE density study, when a BONE density study with vertebral fracture assessment is performed, bill the code for the appropriate BONE density study (e.g., 77080) plus code 77082.

For claims submitted to the Part B MAC:

Place of service guidelines:

Claims for global BONE density measurement (77078, 77080, 77081, and G0130) should indicate one of the following payable places of service for reimbursement: office (11), mobile (15), and independent clinic (49).

If an Independent Diagnostic Testing Facility (IDTF) performs the global service in a location other than its own office location, that location where the service was furnished should be the place of service billed on the claim.

Claims for global ultrasonic BONE density measurement (76977) should indicate one of the following payable places of service for reimbursement: office (11), home (12), assisted living facility (13), group home (14), mobile (15), temporary lodging (16), skilled nursing facility, non-Part A stay (32), custodial care facility (33), and independent clinic (49).

When billing for the technical component only, a TC modifier must be appended to the Procedure  code /HCPCS code. Claims for the technical component only (77078/TC, 77080/TC, 77081/TC, and G0130/TC) should indicate one of the following payable places of service for reimbursement: office (11), mobile (15), independent clinic (49), federally qualified health centers (50) and rural health clinics (72).

Claims for the technical component only for ultrasonic BONE density testing (76977TC) should indicate one of the following payable places of service for reimbursement: office (11); home (12); assisted living facility (13); group home (14); mobile (15); temporary lodging (16), skilled nursing facility, non-Part A stay (32); custodial care facility (33); independent clinic (49), federally qualified health centers (50) and rural health clinics (72).

When billing for the professional component only, a 26 modifier must be appended to the Procedure  code /HCPCS code.

Claims for the professional component only (77078/26, 77080/26, 77081/26, and G0130/26) should indicate one of the following payable places of service for reimbursement: office (11), mobile (15), inpatient hospital (21), outpatient hospital (22), and independent clinic (49).


Bone Mass Measurement (BMM) studies are radiologic, radioisotopic, or other procedures used to:

* Quantify bone mineral density, detect bone loss or determine bone quality
* Establish the diagnosis of osteoporosis
* Assess the response to, or efficacy of, osteoporosis drug therapy

The following procedures are used to measure bone mineral density:
* Dual energy x-ray absorptiometry (DXA)
* Radiographic absorptiometry (RA)
* Bone sonometry (ultrasound)
* Single energy x-ray absorptiometry (SEXA)
* Quantitative computed tomography (QCT)

Earlier technologies, such as single and dual photon absorptiometry (CPT code 78350 or 78351), are no longer used.Guidelines

Each claim must be submitted with the diagnosis codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. The patient’s medical record must document that the patient meets one of the requirements of a “qualified individual” as described in the guidelines below. Documentation must be available upon request. It is the responsibility of the provider to code to the highest level specified. The correct use  of a diagnosis code listed, does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified. BMM tests provided without an accompanying interpretation and report, as part of the test, will be denied as not medically necessary.

CPT 77085 should NOT be billed for screening and is not part of the Preventive Benefit. Member cost share will apply when medically necessary criteria are met.

The following two studies are not covered by Medicare:

* 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 Medicare covers a bone mass measurement for a beneficiary once every two years (if at least 23 months have passed since the month the last bone measurement was performed). The criteria for bone mass measurement every two years are listed below:
* 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).
* 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:
o A woman who has been determined by the physician or qualified non-physician treating her to be estrogendeficient and at clinical risk for osteoporosis, based on her medical history and other indicators

NOTE: Since not every woman who has been prescribed estrogen replacement therapy (ERT) maybe 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 nonphysician practitioner from ordering a bone mass measurement for her. If a bone mass measurement 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 nonphysician  practitioner) will document in her medical record why he or she believes that the woman is estrogen-deficient and at clinical risk for osteoporosis.

o An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral fracture
o An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to 5 mg of Prednisone, or greater, per day for more than 3 months
o An individual with primary hyperparathyroidism
o An individual being monitored to assess the response to or efficacy of an FDA approved osteoporosis drug therapy. This service must be performed using dual energy x-ray absorptiometry system (axial skeleton) –CPT code 77080 and 77085.

* If it is furnished by a qualified supplier or provider of such services, under at least general level of supervision of a physician.

* 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.

* The test is reasonable and necessary for diagnosing, treating or monitoring of a “qualified” individual as defined above. For conditions specified below, Medicare will cover a bone mass measurement for a qualified beneficiary more frequently than every two years, if medically necessary. To be considered, at least eleven months must have elapsed since the previous bone mass measurement test. Such conditions are:

* Monitoring beneficiaries on long-term glucocorticoid (steroid) therapy, equal to 5 mg of Prednisone or greater, per day for more than three months.

* Follow up bone mineral density testing to assess FDA-approved osteoporosis drug therapy until a response to such therapy has been documented over time.

* Confirming baseline BMMs to permit monitoring of beneficiaries in the future. 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), a confirmatory BMM is not covered.


For Procedure code 77080 only:

Below is the list of ICD-10-CM diagnosis codes within subcategory M85.8- that providers may report as covered indications in addition to the current list provided in CR 9252 and its accompanying CMS spreadsheet.

* M85.811 Other specified disorders of bone density and structure, right shoulder

* M85.812 Other specified disorders of bone density and structure, left shoulder

* M85.821 Other specified disorders of bone density and structure, right upper arm

* M85.822 Other specified disorders of bone density and structure, left upper arm

* M85.831 Other specified disorders of bone density and structure, right forearm

* M85.832 Other specified disorders of bone density and structure, left forearm

* M85.841 Other specified disorders of bone density and structure, right hand

* M85.842 Other specified disorders of bone density and structure, left hand

* M85.851 Other specified disorders of bone density and structure, right thigh

* M85.852 Other specified disorders of bone density and structure, left thigh

* M85.861 Other specified disorders of bone density and structure, right lower leg

* M85.862 Other specified disorders of bone density and structure, left lower leg

* M85.871 Other specified disorders of bone density and structure, right ankle and  foot

* M85.872 Other specified disorders of bone density and structure, left ankle and foot

* M85.88 Other specified disorders of bone density and structure, other site

* M85.89 Other specified disorders of bone density and structure, multiple sites

Group 1 Codes:

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

V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS

V67.51 FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED

V82.81 SPECIAL SCREENING FOR OSTEOPOROSIS

HEAD/NECK

Head/Brain w/o contrast . . . . . . . . . . . . . . 70450
Head/Brain w/o & w/ contrast . . . . . . . . . .  . 70470
Mid/Inner Ear w/o contrast . . . . . . . . . . .  . 70480
Mid/Inner Ear w/o & w/ contrast . . . . . . . . . . 70482
Orbit/Sella/Fossa w/o cont. . . . . . . . . . . . . 70480
Orbit/Sella/Fossa w/o & w/ cont. . . . . . . . .  . 70482
Sinuses w/o contrast. . . . . . . . . . . . . . . . 70486
Soft Tissue Neck w/o contrast . . . . . . . . . . . 70490
Soft Tissue Neck w/o & w/ cont . . . . . . . . .  . 70492
Temporal Bones w/o contrast. . . . . . . . .  . . . 70480


SPINE/PELVIS

Cervical w/o contrast. . . . . . . . . . . . . .  . 72125
Cervical w/o & w/ contrast . . . . . . . .  . . 72127
Lumbar w/o contrast . . . . . . . . . . . . . . . 72131
Lumbar w/o & w/ contrast. . . . . . . . . . . 72133
Pelvis w/o contrast . . . . . . . . . . . . . . . . 72192
Pelvis w/ contrast . . . . . . . . . . . . . .  .  . 72193
Pelvis w/o & w/ contrast . . . . . . . . . .  . 72194
Thoracic spine w/o contrast . . . . . . . .  . 72128
Thoracic spine w/o & w/ contrast. . . .  . 72130


POLICY/CRITERIA

Priority Health will limit coverage for BMD studies to central DXA only. Any other BMD studies (e.g. peripheral, such as wrist, finger and heel) are not medically/clinically necessary and, therefore, not covered.

BMD studies will not be prior authorized by Priority Health.

Guidelines on the appropriate use of BMD include information from the National Osteoporosis Foundation and Priority Health’s guidelines in conjunction with the Michigan Quality Improvement Consortium.

A. A one-time measurement of BMD, using one method only, may be considered medically necessary to assess fracture risk and the need for pharmacologic therapy in the following patients considered at risk for osteoporosis, who are also considering treatment to prevent osteoporotic fracture:

1. All women aged 65 and older regardless of risk factors.

2. Men or women with a fracture risk (10-year probability of fracture using FRAX of 9.3%)

a. A FRAX Assessment is done to identify patients for BMD testing when any of the following criteria are met:

i. Personal history of fracture as an adult

ii. History of fragility fracture in a first degree relative

iii. Estrogen deficiency at an early age (<45 p="" years="">
iv. Current cigarette smoking

v. Low body weight (<127 lbs="" p="">
vi. Alcohol 3 or more units per day

vii. Use of oral corticosteroid therapy for more than 3 months


History of osteopenia or osteopenia diagnosed via x-ray

ix. History of Depro-Provera® use

x. Individuals who are at increased risk for fractures due to diseases, conditions or treatments including, but not limited to primary hyperparathyroidism, renal failure (patients on dialysis), decreased mineralization noted on other studies, lifelong low calcium intake, impaired vision, dementia, recent falls, low physical activity, poor health/frailty, and long-term anti-convulsant therapy ( e.g., phenytoin therapy).

3. Individuals beginning or on glucocorticoid therapy, provided intervention is an option. The most commonly used glucocorticoids include prednisone, prednisolone, betamethasone, dexamethasone and decadron.

4. Transplant patients

5. Men with hypogonadism or receiving androgen deprivation treatment.

6. Post menopausal women who present with fractures (to confirm diagnosis and determine disease severity).

B. If the initial BMD measurement was medically necessary as defined above, serial measurements of BMD to monitor treatment response may be considered medically necessary when performed no more frequently than 24 months apart and when a change in treatment plan may be made based on BMD results.

When the need for serial measurements is anticipated in high risk patients who are likely to require treatment, and for obtaining serial measurements, a central DXA BMD measurement should be obtained, as treatment related changes in BMD are not observed at peripheral sites.

C. More frequent bone mass measurements may be considered medically necessary in any of the following circumstances:

1. Monitoring individuals on long-term glucocorticoid (steroid) therapy of more than 3 months duration; or

2. For a confirmatory baseline bone mass measurement to permit monitoring of individuals in the future if the initial bone mass test was performed with a technique that is different from the proposed testing method; or

3. Monitoring of individuals with uncorrected primary hyperparathyroidism.

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