Billing and Coding: Bone Mass Measurement

The following is guidance for billing, coding, and other guidelines in relation to local coverage policy L36460-Bone Mass Measurement. This is an excerpt from the article written by Centers for Medicare & Medicaid Services.

"Documentation Requirements:

The patient’s medical record should include but is not limited to:

• The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,

• Relevant medical history

• Results of pertinent tests/procedures

• Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)+

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

Limitations:

1. Tests not ordered by the physician/qualified non-physician practitioner, who is treating the beneficiary, are not reasonable and necessary.

2. 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, 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. Medicare 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. Beneficiaries 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 under the portable x-ray benefit and will be denied when performed by a portable x-ray supplier. Transportation charges for BMM testing are not covered.

 8. Bone mass measurement tests provided without an accompanying interpretation and report, as part of the test, will be denied as not medically necessary. The report must be separate and distinct from an evaluation and management note/record.

9. 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.

For Claims submitted to the Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators to process their claims.
Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.
Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)"

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