Sunday, July 19, 2015

CPT 77085, 77080, 77083, 76977- Bone mineral density studies


CPT/HCPCS Codes

Procedures may not be billable by all providers. Radiology privileging limitations are in effect.

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

77085 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment

77086 Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA)

G0130 Single energy x-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) (Medicare only)

76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method


Bone Mineral Density Studies

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable codes: 76499, 77078, 77080, 77081, 77085, 76977, 78350, 78351, G0130 Documentation requirements:

The procedure must be ordered by a physician or qualified practitioner after a complete assessment of the patient’s condition determines that a bone mass measurement is medically necessary. If diagnosis, frequency, or documentation does not support medical necessity, coverage will be denied. The need for bone mass measurement more frequently than every 2 years must have documentation defining the medical necessity. Documentation must include the complete medical record including previous bone densitometry study results and any other pertinent test findings, medication lists, and office notes. Letters summarizing the medical record may be useful, but are not considered adequate documentation.

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

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 (DEXA) body composition studies are considered  investigational.” Rationale in the Policy Guidelines section updated. Added information from U.S. Preventive Services Task Force guidelines. The statement: The procedure must be ordered by a physician or qualified practitioner after a complete assessment of the patient’s condition determines that a bone mass measurement is medically necessary. If diagnosis, frequency, or documentation does not support medical necessity, coverage will be denied” was added to the Billing/Coding section. Specialty Matched Consultant



Bone (mineral) density studies are used to evaluate diseases of bone and/or the responses of bone diseases to treatment. The studies access bone mass or density associated with such diseases as osteoporosis, osteomalacia, and renal osteodystrophy. Various single or combined methods of measurement may be required to: (a) diagnose bone disease, (b) monitor the course of bone changes with disease progression, or (c) monitor the course of bone changes with therapy.

Covered methods for measuring bone mineral density include:

• Single energy x-ray absorptiometry (SEXA)

• Dual energy x-ray absorptiometry (DXA)

• Quantitative computed tomography (QCT)

• Bone ultrasound densitometry (BUD)

• Photodensitometry

• Radiographic absorptiometry (RA)

The following bone mass measurements are NOT covered under Medicare because they are not considered reasonable and necessary under section 1862(a)(1)(A) of the Act:

• Single photon absorptiometry (SPA), Procedure code 78350 (effective 01/01/2007)

• Dual photon absorptiometry (DPA), Procedure code 78351.

Bone density can be measured at the wrist, spine, hip or calcaneus. The medical literature is divided on the accuracy of predicting osteoporosis of the spine or hip by measuring peripheral sites (wrist, calcaneus). It does appear, however, that measurement of bone density of the bone involved gives a better measurement of osteoporosis than does measurement of another bone not known to be involved.

Precise calibration of the equipment is required for accuracy and to reduce variation of test results and risk of misclassification of the degree of bone density. Lack of standardization in bone mineral measurement remains an issue, and tests are best done on the same suitably precise instrument to insure accuracy. It is important to use results obtained with the same scanner when comparing a patient to a control population, as systematic differences among scanners have been found. To ensure reliability of bone mass measurements, the densitometry technologist must have proper training in performing this procedure. Malpositioning of a patient or analyzing a scan incorrectly can lead to great errors in bone mineral density studies.

Indications:

Medicare considers a bone mineral density study to be medically reasonable and necessary for the following indications. In addition, all coverage criteria listed below must be met.

1. A patient with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral fracture.

2. A patient 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) – Procedure codes 77080 and 77085.

3. A patient with known primary hyperparathyroidism.

4. A patient 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 3 months.

5. A woman who has been determined by the physician or a qualified non physician practitioner treating her to 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) 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.

An estrogen-deficient woman qualifies if she is at clinical risk for osteoporosis, based on her medical history and other findings. Unless this applies and is documented in the medical record, the service is not payable.

In addition to gender and estrogen-deficiency, pertinent factors acceptable as documentation for the clinical risk include, but are not limited to: age, family history and personal history of fractures as an adult, race, bone structure and body weight, premature menopause, lifestyle, medications, chronic diseases, and other genetic and environmental factors. Symptoms and findings of osteoporosis include, but are not limited to: back pain, loss of height, curving spine, and chest x-ray showing osteopenia.

Bone density measurement is not a covered Medicare benefit when utilized for osteoporosis screening in an estrogen-deficient woman, who has not been determined by the physician or a qualified nonphysician practitioner treating her to be at clinical risk for osteoporosis, based on her medical history and other findings.

If - in addition to gender and estrogen-deficiency - a woman has been determined to be at clinical risk for osteoporosis, based on her history and other findings, and this has been appropriately documented in the medical record, this Carrier will interpret the menopausal state as symptomatic.


 DESCRIPTION

Bone mineral density (BMD) can be measured with a variety of techniques in a variety of sites. Sites are broadly subdivided into central sites (e.g. hip or spine) and peripheral sites (e.g. wrist, finger, heel). While BMD measurements are predictive of fragility fractures at all sites, central measurements of the hip and spine are the most predictive. Additionally, fractures of the hip and spine (e.g. vertebral fractures) are the most clinically relevant. The most commonly used techniques are Dual X-ray Absorptiometry (DXA), Quantitative computed tomography (QCT), and Ultrasound Densitometry.

Dual-energy x-ray absorptiometry (DXA) is considered the gold standard because it is the most extensively validated test against fracture outcomes. In general, a central DXA BMD measurement should be strongly considered for initial screening purposes due to its reproducibility and ability to simultaneously establish the diagnosis of osteoporosis and provide a baseline if one is needed. This approach is endorsed by the National Osteoporosis Foundation’s Clinician’s Guide to Prevention and Treatment of Osteoporosis as well as the Michigan Quality Improvement Consortium Guideline:

Management and Prevention of Osteoporosis 

Background:

Osteoporosis, defined as low bone mass leading to an increased risk of fragility fractures, is an extremely common disease in the elderly due to age-related bone loss in both sexes and menopause-related bone loss in women. Current practice guidelines published by the National Osteoporosis Foundation (NOF) recommend that measurement of bone mineral density (BMD) be performed in all women over the age of 65 and in postmenopausal women with additional risk factors. Additional risk factors include a personal history of fracture as an adult, history of fracture in a first-degree relative, current cigarette smoking, and low body weight (<127 age.="" also="" are="" at="" bmd="" bone="" for="" glucocorticoid="" initiating="" lbs="" loss="" matter="" measurements="" no="" often="" p="" patients="" performed="" prior="" receiving="" risk="" the="" therapy.="" therapy="" therefore="" to="" what="">
BMD is one of the key determinants of the need for pharmacologic therapy. BMD is typically expressed in terms of the number of standard deviations (SD) the BMD falls below the mean for young, healthy adults. This number is termed the T score.

The NOF guidelines recommend that pharmacologic therapy be initiated in women with T scores below –2 in the absence of other risk factors, and in women with BMD T scores below –1.5 if other risk factors are present. Current pharmacologic options include hormone replacement therapy, bisphosphonates such as alendronate (Fosamax), selective estrogen receptor modulators (SERMs) such as raloxifene (Evista), and calcitonin. While BMD measurements are typically used to determinethe need for pharmacologic therapy, serial monitoring of BMD to determine treatment response is also performed.

Dual-energy x-ray absorptiometry (DXA) is considered the gold standard because it is the most extensively validated test against fracture outcomes. When used in the same patients, DXA machines from different manufacturers differ in the proportion of patients diagnosed to have osteoporosis by 6 to 15 percent. Published studies consistently show that the probability of receiving a diagnosis of osteoporosis depends on the choice of test and site. One analytical study, for example, found that
6 percent of women older than 60 years of age would receive a diagnosis of osteoporosis if DXA of the total hip were used as the only test, compared with 14 percent for DXA of the lumbar spine, 3 percent with quantitative ultrasonography, and 50 percent with quantitative computed tomography (Faulker, 1999).

A meta-analysis assessed 23 publications from 11 separate prospective cohort studies published before 1996. Nearly all of the data were from women in their late 60s or older. No studies of ultrasonography were included. The meta-analysis indicated that DXA at the femoral neck predicted hip fracture better than measurements at other sites, and was comparable to forearm measurements for predicting fractures at other sites. For bone density measurements at the femoral neck, the pooled relative risk per decrease of one SD in bone density was 2.6 (CI, 2.0-3.5). In direct comparisons, heel ultrasonography was slightly worse than but comparable to DXA of the hip in women older than 65 years of age). For both tests, a result in the osteoporotic range is associated with an increased short-term probability of hip fracture. No data compare DXA and ultrasonography for prediction of fracture in women younger than 65 years of age.

Special Note: This policy is based on the recommendations of Priority Health’s Technology Assessment Committee on December 3, 2004.
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CODING

The following CPT codes are medically necessary for BlueCHiP for Medicare only, and not medically necessary for Commercial products: 76977, 77086

The following CPT code is not separately reimbursed for BlueCHiP for Medicare members, and not medically necessary for Commercial products:

G0130 BlueCHiP for Medicare and Commercial

The following CPT codes are medically necessary: 77078, 77080, 77081, 77085

The following CPT code is not separately reimbursed: 77082 (Code deleted January 1, 2015)

The following CPT codes are considered not medically necessary: 78350, 78351

Billing 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.



ICD-10 Diagnoses that support screening central DEXA (77080, 77085) for commercial members:

Z00.00 Encounter for general adult medical examination without abnormal findings
Z00.01 Encounter for general adult medical examination with abnormal findings
Z13.820 Encounter for screening for osteoporosis
Z78.0 Asymptomatic menopausal state

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V. CODING INFORMATION

ICD-9 Codes that may apply (for dates of service on or before September 30, 2015):

242.00 242.91 Thyrotoxicosis

246.0 Disorders of thyrocalcitonin secretion

252.00 – 252.08 Hyperparathyroidism

253.2 Panhypopituitarism

255.0 Cushing’s Syndrome

256.2 Postablative ovarian failure

256.31 Premature menopause

256.39 Other ovarian failure

257.2 Other testicular hypofunction

259.3 Ectopic hormone secretion, not elsewhere classified

262 Severe, protein-calorie malnutrition

263.0 – 263.9 Other protein-calorie malnutrition

268.2 Osteomalacia, unspecified

275.40 – 275.49 Disorders of calcium metabolism

555.0 – 555.9 Regional enteritis

556.0 – 556.9 Ulcerative colitis

579.0 – 579.9 Intestinal malabsorption

585.1 – 585.9 Chronic kidney disease

588.0 – 588.9 Disorders resulting from impaired renal function

626.0 Absence of menstruation

627.0 – 627.9 Menopausal and postmenopausal disorders

733.10 – 733.19 Pathologic fracture

733.00 – 733.09 Osteoporosis

733.90 Disorder of bone and cartilage, unspecified

733.93 Stress fracture of tibia or fibula

733.94 Stress fracture of the metatarsals

733.95 Stress fracture of other bone

737.10 Kyphosis (acquired) (postural)

753.12 – 753.19 Cystic kidney disease

758.6 Gonadal dysgenesis

781.91 Loss of height

805.00 - 805.9 Fracture of vertebral column without mention of spinal cord injury

806.00 – 806.9 Fracture of vertebral column with spinal cord injury

820.00 – 820.9 Fracture of neck of femur

962.0 Poisoning; adrenal cortical steroids

995.20 Unspecified adverse effect of unspecified drug, medicinal and biological substance

V17.81 Family history of, Osteoporosis

V45.77 Acquired absence of genital organs

V49.81 Asymptomatic postmenopausal status (age related) (natural)

V50.42 Prophylactic removal of ovary

V58.65 Long-term (current) use of steroids

V58.68 Long term (current) use of bisphosphonates

V67.51 Following completed treatment with high-risk medications, not elsewhere classified

V58.69 Long-term (current) use of other medications

V67.59 Follow up examination, following completed treatment with high-risk medications, other

ICD-10 Codes that may apply (for dates of service on or after October 1, 2015):

E05.00 - E05.91 Thyrotoxicosis

E07.0 Hypersecretion of calcitonin

E20.1 – 20.9 Hypoparathyroidism

E21.1 – E21.5 Hyperparathyroidism and other disorders of parathyroid gland

E23.0 Hypopituitarism

E24.0 Pituitary-dependent Cushing's disease

E24.2 Drug-induced Cushing's syndrome

E24.4 Alcohol-induced pseudo-Cushing's syndrome

E24.8 Other Cushing's syndrome

E24.9 Cushing's syndrome, unspecified

E28.310 - E28.39 Primary ovarian failure

E29.1 Testicular hypofunction

E34.2 Ectopic hormone secretion, not elsewhere classified

E43 Unspecified severe protein-calorie malnutrition

E44.0 – E44.1 Protein-calorie malnutrition

E45 Retarded development following protein-calorie malnutrition

E46 Unspecified protein-calorie malnutrition

E64.0 Sequelae of protein-calorie malnutrition

E83.50 - E83.59 Disorders of calcium metabolism

E89.40 Asymptomatic postprocedural ovarian failure

E89.41 Symptomatic postprocedural ovarian failure

K50.00 - K50.919 Crohn's disease

K51.00 – K51.919 Ulcerative colitis

K90.0 – K90.9 Intestinal malabsorption

K91.2 Postsurgical malabsorption, not elsewhere classified

M40.00 - M40.299 Kyphosis

M48.40xA – M48.48xS Fatigue fracture of vertebra

M48.50xA – M48.58xS Collapsed vertebra

M80.00xA - M80.88XS Osteoporosis with current pathological fracture

M81.0 – M81.8 Osteoporosis without current pathological fracture

M83.0 – M83.9 Adult osteomalacia

M84.30xA – M84.9 Disorder of continuity of bone

M85.80 – M85.9 Disorder of bone density and structure

M89.9 Disorder of bone, unspecified

M94.9 Disorder of cartilage, unspecified

N18.1 – N18.9 Chronic kidney disease

N25.0 – N25.9 Disorders resulting from impaired renal tubular function

N91.0 – N91.5 Absent, scanty and rare menstruation

N95.0 – N95.9 Menopausal and other perimenopausal disorders

Q61.00 – Q61.9 Cystic kidney disease

Q96.0 – Q96.9 Turner's syndrome

R29.890 Loss of height

S12.000A - S12.9xxS Fracture of cervical vertebra and other parts of neck

S14.101A – S14.9xxS Injury of nerves and spinal cord at neck level

S22.000A - S22.089S Fracture of thoracic vertebra

S24.101A – S24.159S Other and unspecified injuries of thoracic spinal cord

S32.000A - S32.2xxS Fracture of lumbar spine

S34.101A - S34.3xxS Injury of lumbar and sacral spinal cord

S72.001A - S72.26XS Fracture of neck of right femur

S79.001A - S79.099S Physeal fracture of upper end of femur

T38.0x1A – T38.0x5S Poisoning by, adverse effect of and underdosing of glucocorticoids and synthetic analogues

Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm

Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm

Z40.02 Encounter for prophylactic removal of ovary

Z78.0 Asymptomatic menopausal state

Z79.3 Long term (current) use of hormonal contraceptives

Z79.51 Long term (current) use of inhaled steroids

Z79.52 Long term (current) use of systemic steroids

Z79.891 Long term (current) use of opiate analgesic

Z79.899 Other long term (current) drug therapy

Z90.721 Acquired absence of ovaries, unilateral

Z90.722 Acquired absence of ovaries, bilateral

Z90.79 Acquired absence of other genital organ(s)

ICD-9 Diagnoses that support screening central DEXA (77080, 77085) for commercial members (for dates of service on or before  September 30, 2015):

V70.0 Routine general medical examination at a health care facility

V49.81 Asymptomatic Postmenopausal postmenopausal status (age related) (natural)

V82.81 Special screening for osteoporosis

ICD-10 Diagnoses that support screening central DEXA (77080, 77085) for commercial members (for dates of service on or after October 1, 2015):

Z00.00 Encounter for general adult medical examination without abnormal findings

Z00.01 Encounter for general adult medical examination with abnormal findings

Z13.820 Encounter for screening for osteoporosis

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