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1 Local Coverage Determination (LCD): Bone Mass Measurement (L36460) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information Contractor Name Contract Type Contract Number Jurisdiction State(s) CGS Administrators, LLC MAC - Part A MAC A N/A Kentucky CGS Administrators, LLC MAC - Part B MAC B N/A Kentucky CGS Administrators, LLC MAC - Part A MAC A N/A Ohio CGS Administrators, LLC MAC - Part B MAC B N/A Ohio Back to Top LCD Information Document Information LCD ID L36460 LCD Title Bone Mass Measurement AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Original Effective Date For services performed on or after 02/01/2016 Revision Effective Date For services performed on or after 02/01/2016 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date 12/17/2015 Notice Period End Date 01/31/2016 The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS). National Printed on 12/2/2016. Page 1 of 24

2 Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR [b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See 1869(f)(1)(A)(i) of the Social Security Act. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Section 1861(r) provides the definition of a physician. Section 1861(s)(2)(V)(15) includes bone mass measurement as a physician service. Section 1861(rr) provides the definition of bone mass measurement. Code of Federal Regulations: Title IV of the Balanced Budget Act of 1997, Section 4106 includes language providing for Medicare coverage of bone mass measurement procedures, and coverage of FDA-approved bone mass measurement techniques and equipment for "qualified" individuals. These procedures are only covered when medically necessary. CMS Publications: CMS Manual System, Pub , Medicare Benefit Policy Manual, Chapter 15: 80.5 Bone Mass Measurements (BMMs) CMS Manual System, Pub , Medicare National Coverage Determinations, Chapter 1: Bone (Mineral) Density Studies (Effective January 1, 2007) CMS Manual System, Pub , Medicare Claims Processing Manual, Chapter 13: 140 Bone Mass Measurements (BMMs). Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Bone mass measurement (BMM) studies are radiologic, radioisotopic or other procedures that meet all of the following conditions: quantify bone mineral density, detect bone loss or determine bone quality; are performed with either a bone densitometer (other than single-photon or dual-photon absorptiometry) or a bone sonometer system that has been cleared for marketing for BMM by the Food and Drug Administration (FDA) under 21 CFR part 807, or approved for marketing under 21 CFR part 814. include a physician's interpretation of the results. The following procedures are used to measure bone mineral density: dual energy x-ray absorptiometry (DXA) radiographic absorptiometry (RA); Printed on 12/2/2016. Page 2 of 24

3 bone sonometry (ultrasound); single energy x-ray absorptiometry; (SEXA), quantitative computed tomography (QCT). Earlier technologies, such as single and dual photon absorptiometry ( CPT code or 78351), are no longer used. Indications: Medicare will cover a bone mass measurement test when it meets all of the following criteria: 1. It is performed with one of the covered tests listed above. 2. 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 five categories listed below: &deg A woman who has been determined by the physician or a qualified nonphysician practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings; &deg An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral ; &deg An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to 5 mg of prednisone, or greater, per day, for more than three (3) months; &deg An individual with primary hyperparathyroidism; &deg An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy. 3. It is furnished by a qualified supplier or provider of such services under at least the general level of supervision of a physician as defined in 42 CFR (b). 4. 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. 5. The test is reasonable and necessary for diagnosing, treating, or monitoring of a "qualified individual" as defined above in #2. Monitoring is defined as subsequent testing in patients on FDA-approved drug therapy. 6. Medicare may cover a bone mass measurement for a beneficiary once every 2 years (if at least 23 months have passed since the month the last bone mass measurement was performed). 7. For conditions specified, Medicare will cover a bone mass measurement for a qualified beneficiary more frequently than every two years, if medically necessary for the diagnosis or treatment of the patient and if related to the condition listed. In these instances payment may be made for tests performed after eleven months have elapsed since the previous bone mass measurement test. Examples include, but are not limited to, the following medical circumstance: &deg Monitoring beneficiaries on long-term glucocorticoid ( 5 mg/day) therapy of more than 3 months (patients must be on glucocorticoids for greater than three months duration, but BMM monitoring is at yearly intervals). &deg Confirming baseline BMMs to permit monitoring of beneficiaries in the future. In addition, bone mass measurement for the following may be reimbursed more frequently than every two years: &deg Follow up bone mineral density testing to assess FDA-approved osteoporosis drug therapy until a response to such therapy has been documented over time. Printed on 12/2/2016. Page 3 of 24

4 8. A confirmatory baseline BMM is only covered when it is performed with a dual-energy x-ray absorptiometry system (axial skeleton) and 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 initial BMM was performed by a dual-energy x-ray absorptiometry system (axial skeleton). 9. For an individual being monitored to assess the response to, or efficacy of, an FDA-approved osteoporosis drug therapy, the test is only covered if it is performed with a dual-energy x-ray absorptiometry system (axial skeleton). 10. The test must include a physician's interpretation of the results. 11. 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/other qualified nonphysician practitioner from ordering a bone mass measurement test for her. If a bone mass measurement test is ordered for a woman following a careful evaluation of her medical need, it is expected that the ordering/treating physician/qualified non-physician practitioner will document, why he or she believes that the woman is estrogen deficient and at clinical risk for osteoporosis. 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 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 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. Bone mass measurement tests will be denied as not medically necessary if performed by a nonphysician practitioner. 10. CPT code is considered by Medicare to represent vertebral assessment only. Because code 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 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. Other Comments: 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 Printed on 12/2/2016. Page 4 of 24

5 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 nonphysicians, 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 , , and ; 58 FR 18543, April 7, 2000.) Back to Top Coding Information Bill Type : 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. 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient 034x Home Health Services not under a plan of treatment 071x Clinic - Rural Health 072x Clinic - Hospital Based or Independent Renal Dialysis Center 073x Clinic - Freestanding 077x Clinic - Federally Qualified Health Center (FQHC) 085x Critical Access Hospital Revenue : Contractors may specify Revenue to help providers identify those Revenue typically used to report this service. In most instances Revenue are purely advisory. Unless specified in the policy, services reported under other Revenue are equally subject to this coverage determination. Complete absence of all Revenue indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue. Contractors may specify Revenue to help providers identify those Revenue typically used to report this service. In most instances Revenue are purely advisory; unless specified in the policy services reported under other Revenue are equally subject to this coverage determination. Complete absence of all Revenue indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue. Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC. Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes Radiology - Diagnostic - General Classification 0333 Radiology - Therapeutic and/or Chemotherapy Administration - Radiation Therapy 0340 Nuclear Medicine - General Classification 0341 Nuclear Medicine - Diagnostic 0350 CT Scan - General Classification Printed on 12/2/2016. Page 5 of 24

6 0352 CT Scan - Body Scan 0400 Other Imaging Services - General Classification 0402 Other Imaging Services - Ultrasound 0520 Freestanding Clinic - General Classification 0521 Freestanding Clinic - Clinic Visit by Member to RHC/FQHC 0522 Freestanding Clinic - Home Visit by RHC/FQHC Practitioner 0523 Freestanding Clinic - Family Practice Clinic Freestanding Clinic - Visit by RHC/FQHC Practitioner to a Member in a SNF or Skilled Swing Bed in a 0524 Covered Part A Stay Freestanding Clinic - Visit by RHC/FQHC Practitioner to a Member in a SNF (not in a Covered Part A Stay) 0525 or NF or ICF MR or Other Residential Facility 0527 Freestanding Clinic - Visiting Nurse Service(s) to a Member's Home when in a Home Health Shortage Area 0610 Magnetic Resonance Technology (MRT) - General Classification 0612 Magnetic Resonance Technology (MRT) - MRI - Spinal Cord/Spine 0616 Magnetic Resonance Technology (MRT) - MRA - Lower Extremities 0960 Professional Fees - General Classification 0969 Professional Fees - Other Professional Fee 0972 Professional Fees - Radiology - Diagnostic 0982 Professional Fees - Outpatient Services 0983 Professional Fees - Clinic CPT/HCPCS Group 1 Paragraph: CPT codes and are non-covered procedures under Medicare. Group 1 : ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETATION, PERIPHERAL SITE(S), ANY METHOD COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES, AXIAL SKELETON (EG, HIPS, PELVIS, SPINE) DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE) DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; APPENDICULAR SKELETON (PERIPHERAL) (EG, RADIUS, WRIST, HEEL) DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE), INCLUDING VERTEBRAL FRACTURE ASSESSMENT BONE DENSITY (BONE MINERAL CONTENT) STUDY, 1 OR MORE SITES; SINGLE PHOTON ABSORPTIOMETRY BONE DENSITY (BONE MINERAL CONTENT) STUDY, 1 OR MORE SITES; DUAL PHOTON ABSORPTIOMETRY, 1 OR MORE SITES SINGLE ENERGY X-RAY ABSORPTIOMETRY (SEXA) BONE DENSITY STUDY, ONE OR MORE SITES; G0130 APPENDICULAR SKELETON (PERIPHERAL) (E.G., RADIUS, WRIST, HEEL) ICD-10 that Support Medical Necessity Group 1 Paragraph: It is the responsibility of the provider to code to the highest level specified in the ICD-10- CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination Group 1 : ICD-10 E21.0 Primary hyperparathyroidism E21.3 Hyperparathyroidism, unspecified E23.0 Hypopituitarism E24.0 Pituitary-dependent Cushing's disease E E24.4 Drug-induced Cushing's syndrome - Alcohol-induced pseudo-cushing's syndrome Printed on 12/2/2016. Page 6 of 24

7 E E24.9 Other Cushing's syndrome - Cushing's syndrome, unspecified E Symptomatic premature menopause E Asymptomatic premature menopause E28.39 Other primary ovarian failure E34.2 Ectopic hormone secretion, not elsewhere classified E E89.41 Asymptomatic postprocedural ovarian failure - Symptomatic postprocedural ovarian failure M48.50XA Collapsed vertebra, not elsewhere classified, site unspecified, initial encounter for M48.51XA Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, initial encounter for M48.52XA Collapsed vertebra, not elsewhere classified, cervical region, initial encounter for M48.53XA Collapsed vertebra, not elsewhere classified, cervicothoracic region, initial encounter for M48.54XA Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for M48.55XA Collapsed vertebra, not elsewhere classified, thoracolumbar region, initial encounter for M48.56XA Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for M48.57XA Collapsed vertebra, not elsewhere classified, lumbosacral region, initial encounter for M48.58XA Collapsed vertebra, not elsewhere classified, sacral and sacrococcygeal region, initial encounter for M80.08XA Age-related osteoporosis with current pathological, vertebra(e), initial encounter for M80.88XA Other osteoporosis with current pathological, vertebra(e), initial encounter for M81.0 Age-related osteoporosis without current pathological M81.6 Localized osteoporosis [Lequesne] M81.8 Other osteoporosis without current pathological M84.58XA Pathological in neoplastic disease, other specified site, initial encounter for M84.68XA Pathological in other disease, other site, initial encounter for M Other specified disorders of bone density and structure, right shoulder M Other specified disorders of bone density and structure, left shoulder M Other specified disorders of bone density and structure, right upper arm M Other specified disorders of bone density and structure, left upper arm M Other specified disorders of bone density and structure, right forearm M Other specified disorders of bone density and structure, left forearm M Other specified disorders of bone density and structure, left hand M Other specified disorders of bone density and structure, right thigh M Other specified disorders of bone density and structure, left thigh M Other specified disorders of bone density and structure, right lower leg M Other specified disorders of bone density and structure, left lower leg M Other specified disorders of bone density and structure, right ankle and foot M 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 M85.9 Disorder of bone density and structure, unspecified M89.9 Disorder of bone, unspecified M94.9 Disorder of cartilage, unspecified N92.4 Excessive bleeding in the premenopausal period N N95.2 Postmenopausal bleeding - Postmenopausal atrophic vaginitis Other specified menopausal and perimenopausal disorders - Unspecified menopausal and N N95.9 perimenopausal disorder Q78.0 Osteogenesis imperfecta Q Q96.4 Karyotype 45, X - Mosaicism, 45, X/other cell line(s) with abnormal sex chromosome Q Q96.9 Other variants of Turner's syndrome - Turner's syndrome, unspecified Abnormal findings on diagnostic imaging of limbs - Abnormal findings on diagnostic imaging of R R93.7 other parts of musculoskeletal system S12.000A Unspecified displaced of first cervical vertebra, initial encounter for closed S12.000B Unspecified displaced of first cervical vertebra, initial encounter for open S12.001A Unspecified nondisplaced of first cervical vertebra, initial encounter for closed S12.001B Unspecified nondisplaced of first cervical vertebra, initial encounter for open S12.01XA Stable burst of first cervical vertebra, initial encounter for closed Printed on 12/2/2016. Page 7 of 24

8 S12.01XB S12.02XA S12.02XB S12.030A S12.030B S12.031A S12.031B S12.040A S12.040B S12.041A S12.041B S12.090A S12.090B S12.091A S12.091B S12.100A S12.100B S12.101A S12.101B S12.110A S12.110B S12.111A S12.111B S12.112A S12.112B S12.120A S12.120B S12.121A S12.121B S12.130A S12.130B S12.131A S12.131B S12.14XA S12.14XB S12.150A S12.150B S12.151A S12.151B S12.190A S12.190B S12.191A S12.191B S12.200A S12.200B S12.201A S12.201B S12.230A S12.230B Stable burst of first cervical vertebra, initial encounter for open Unstable burst of first cervical vertebra, initial encounter for closed Unstable burst of first cervical vertebra, initial encounter for open Displaced posterior arch of first cervical vertebra, initial encounter for closed Displaced posterior arch of first cervical vertebra, initial encounter for open Nondisplaced posterior arch of first cervical vertebra, initial encounter for closed Nondisplaced posterior arch of first cervical vertebra, initial encounter for open Displaced lateral mass of first cervical vertebra, initial encounter for closed Displaced lateral mass of first cervical vertebra, initial encounter for open Nondisplaced lateral mass of first cervical vertebra, initial encounter for closed Nondisplaced lateral mass of first cervical vertebra, initial encounter for open Other displaced of first cervical vertebra, initial encounter for closed Other displaced of first cervical vertebra, initial encounter for open Other nondisplaced of first cervical vertebra, initial encounter for closed Other nondisplaced of first cervical vertebra, initial encounter for open Unspecified displaced of second cervical vertebra, initial encounter for closed Unspecified displaced of second cervical vertebra, initial encounter for open Unspecified nondisplaced of second cervical vertebra, initial encounter for closed Unspecified nondisplaced of second cervical vertebra, initial encounter for open Anterior displaced Type II dens, initial encounter for closed Anterior displaced Type II dens, initial encounter for open Posterior displaced Type II dens, initial encounter for closed Posterior displaced Type II dens, initial encounter for open Nondisplaced Type II dens, initial encounter for closed Nondisplaced Type II dens, initial encounter for open Other displaced dens, initial encounter for closed Other displaced dens, initial encounter for open Other nondisplaced dens, initial encounter for closed Other nondisplaced dens, initial encounter for open Unspecified traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for closed Unspecified traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for open Unspecified traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter for closed Unspecified traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter for open Type III traumatic spondylolisthesis of second cervical vertebra, initial encounter for closed Type III traumatic spondylolisthesis of second cervical vertebra, initial encounter for open Other traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for closed Other traumatic displaced spondylolisthesis of second cervical vertebra, initial encounter for open Other traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter for closed Other traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter for open Other displaced of second cervical vertebra, initial encounter for closed Other displaced of second cervical vertebra, initial encounter for open Other nondisplaced of second cervical vertebra, initial encounter for closed Other nondisplaced of second cervical vertebra, initial encounter for open Unspecified displaced of third cervical vertebra, initial encounter for closed Unspecified displaced of third cervical vertebra, initial encounter for open Unspecified nondisplaced of third cervical vertebra, initial encounter for closed Unspecified nondisplaced of third cervical vertebra, initial encounter for open Unspecified traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for closed Printed on 12/2/2016. Page 8 of 24

9 S12.231A S12.231B S12.24XA S12.24XB S12.250A S12.250B S12.251A S12.251B S12.290A S12.290B S12.291A S12.291B S12.300A S12.300B S12.301A S12.301B S12.330A S12.330B S12.331A S12.331B S12.34XA S12.34XB S12.350A S12.350B S12.351A S12.351B S12.390A S12.390B S12.391A S12.391B S12.400A S12.400B S12.401A S12.401B S12.430A S12.430B S12.431A S12.431B S12.44XA Unspecified traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for open Unspecified traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for closed Unspecified traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for open Type III traumatic spondylolisthesis of third cervical vertebra, initial encounter for closed Type III traumatic spondylolisthesis of third cervical vertebra, initial encounter for open Other traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for closed Other traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for open Other traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for closed Other traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for open Other displaced of third cervical vertebra, initial encounter for closed Other displaced of third cervical vertebra, initial encounter for open Other nondisplaced of third cervical vertebra, initial encounter for closed Other nondisplaced of third cervical vertebra, initial encounter for open Unspecified displaced of fourth cervical vertebra, initial encounter for closed Unspecified displaced of fourth cervical vertebra, initial encounter for open Unspecified nondisplaced of fourth cervical vertebra, initial encounter for closed Unspecified nondisplaced of fourth cervical vertebra, initial encounter for open Unspecified traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for closed Unspecified traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for open Unspecified traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for closed Unspecified traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for open Type III traumatic spondylolisthesis of fourth cervical vertebra, initial encounter for closed Type III traumatic spondylolisthesis of fourth cervical vertebra, initial encounter for open Other traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for closed Other traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for open Other traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for closed Other traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for open Other displaced of fourth cervical vertebra, initial encounter for closed Other displaced of fourth cervical vertebra, initial encounter for open Other nondisplaced of fourth cervical vertebra, initial encounter for closed Other nondisplaced of fourth cervical vertebra, initial encounter for open Unspecified displaced of fifth cervical vertebra, initial encounter for closed Unspecified displaced of fifth cervical vertebra, initial encounter for open Unspecified nondisplaced of fifth cervical vertebra, initial encounter for closed Unspecified nondisplaced of fifth cervical vertebra, initial encounter for open Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for open Unspecified traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed Unspecified traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for open Type III traumatic spondylolisthesis of fifth cervical vertebra, initial encounter for closed Printed on 12/2/2016. Page 9 of 24

10 S12.44XB S12.450A S12.450B S12.451A S12.451B S12.490A S12.490B S12.491A S12.491B S12.500A S12.500B S12.501A S12.501B S12.530A S12.530B S12.531A S12.531B S12.54XA S12.54XB S12.550A S12.550B S12.551A S12.551B S12.590A S12.590B S12.591A S12.591B S12.600A S12.600B S12.601A S12.601B S12.630A S12.630B S12.631A S12.631B S12.64XA S12.64XB S12.650A S12.650B S12.651A Type III traumatic spondylolisthesis of fifth cervical vertebra, initial encounter for open Other traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed Other traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for open Other traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed Other traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for open Other displaced of fifth cervical vertebra, initial encounter for closed Other displaced of fifth cervical vertebra, initial encounter for open Other nondisplaced of fifth cervical vertebra, initial encounter for closed Other nondisplaced of fifth cervical vertebra, initial encounter for open Unspecified displaced of sixth cervical vertebra, initial encounter for closed Unspecified displaced of sixth cervical vertebra, initial encounter for open Unspecified nondisplaced of sixth cervical vertebra, initial encounter for closed Unspecified nondisplaced of sixth cervical vertebra, initial encounter for open Unspecified traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for closed Unspecified traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for open Unspecified traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial encounter for closed Unspecified traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial encounter for open Type III traumatic spondylolisthesis of sixth cervical vertebra, initial encounter for closed Type III traumatic spondylolisthesis of sixth cervical vertebra, initial encounter for open Other traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for closed Other traumatic displaced spondylolisthesis of sixth cervical vertebra, initial encounter for open Other traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial encounter for closed Other traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial encounter for open Other displaced of sixth cervical vertebra, initial encounter for closed Other displaced of sixth cervical vertebra, initial encounter for open Other nondisplaced of sixth cervical vertebra, initial encounter for closed Other nondisplaced of sixth cervical vertebra, initial encounter for open Unspecified displaced of seventh cervical vertebra, initial encounter for closed Unspecified displaced of seventh cervical vertebra, initial encounter for open Unspecified nondisplaced of seventh cervical vertebra, initial encounter for closed Unspecified nondisplaced of seventh cervical vertebra, initial encounter for open Unspecified traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for closed Unspecified traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for open Unspecified traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial encounter for closed Unspecified traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial encounter for open Type III traumatic spondylolisthesis of seventh cervical vertebra, initial encounter for closed Type III traumatic spondylolisthesis of seventh cervical vertebra, initial encounter for open Other traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for closed Other traumatic displaced spondylolisthesis of seventh cervical vertebra, initial encounter for open Printed on 12/2/2016. Page 10 of 24

11 S12.651B S12.690A S12.690B S12.691A S12.691B S12.9XXA S22.000A S22.000B S22.001A S22.001B S22.002A S22.002B S22.008A S22.008B S22.009A S22.009B S22.010A S22.010B S22.011A S22.011B S22.018A S22.018B S22.019A S22.019B S22.020A S22.020B S22.021A S22.021B S22.022A S22.022B S22.028A S22.028B S22.029A S22.029B S22.030A S22.030B S22.031A S22.031B S22.032A S22.032B S22.038A S22.038B S22.039A S22.039B S22.040A S22.040B S22.041A S22.041B S22.042A S22.042B S22.048A S22.048B S22.049A S22.049B S22.050A Other traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial encounter for closed Other traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial encounter for open Other displaced of seventh cervical vertebra, initial encounter for closed Other displaced of seventh cervical vertebra, initial encounter for open Other nondisplaced of seventh cervical vertebra, initial encounter for closed Other nondisplaced of seventh cervical vertebra, initial encounter for open Fracture of neck, unspecified, initial encounter Wedge compression of unspecified thoracic vertebra, initial encounter for closed Wedge compression of unspecified thoracic vertebra, initial encounter for open Stable burst of unspecified thoracic vertebra, initial encounter for closed Stable burst of unspecified thoracic vertebra, initial encounter for open Unstable burst of unspecified thoracic vertebra, initial encounter for closed Unstable burst of unspecified thoracic vertebra, initial encounter for open Other of unspecified thoracic vertebra, initial encounter for closed Other of unspecified thoracic vertebra, initial encounter for open Unspecified of unspecified thoracic vertebra, initial encounter for closed Unspecified of unspecified thoracic vertebra, initial encounter for open Wedge compression of first thoracic vertebra, initial encounter for closed Wedge compression of first thoracic vertebra, initial encounter for open Stable burst of first thoracic vertebra, initial encounter for closed Stable burst of first thoracic vertebra, initial encounter for open Other of first thoracic vertebra, initial encounter for closed Other of first thoracic vertebra, initial encounter for open Unspecified of first thoracic vertebra, initial encounter for closed Unspecified of first thoracic vertebra, initial encounter for open Wedge compression of second thoracic vertebra, initial encounter for closed Wedge compression of second thoracic vertebra, initial encounter for open Stable burst of second thoracic vertebra, initial encounter for closed Stable burst of second thoracic vertebra, initial encounter for open Unstable burst of second thoracic vertebra, initial encounter for closed Unstable burst of second thoracic vertebra, initial encounter for open Other of second thoracic vertebra, initial encounter for closed Other of second thoracic vertebra, initial encounter for open Unspecified of second thoracic vertebra, initial encounter for closed Unspecified of second thoracic vertebra, initial encounter for open Wedge compression of third thoracic vertebra, initial encounter for closed Wedge compression of third thoracic vertebra, initial encounter for open Stable burst of third thoracic vertebra, initial encounter for closed Stable burst of third thoracic vertebra, initial encounter for open Unstable burst of third thoracic vertebra, initial encounter for closed Unstable burst of third thoracic vertebra, initial encounter for open Other of third thoracic vertebra, initial encounter for closed Other of third thoracic vertebra, initial encounter for open Unspecified of third thoracic vertebra, initial encounter for closed Unspecified of third thoracic vertebra, initial encounter for open Wedge compression of fourth thoracic vertebra, initial encounter for closed Wedge compression of fourth thoracic vertebra, initial encounter for open Stable burst of fourth thoracic vertebra, initial encounter for closed Stable burst of fourth thoracic vertebra, initial encounter for open Unstable burst of fourth thoracic vertebra, initial encounter for closed Unstable burst of fourth thoracic vertebra, initial encounter for open Other of fourth thoracic vertebra, initial encounter for closed Other of fourth thoracic vertebra, initial encounter for open Unspecified of fourth thoracic vertebra, initial encounter for closed Unspecified of fourth thoracic vertebra, initial encounter for open Wedge compression of T5-T6 vertebra, initial encounter for closed Printed on 12/2/2016. Page 11 of 24

12 S22.050B Wedge compression of T5-T6 vertebra, initial encounter for open S22.051A Stable burst of T5-T6 vertebra, initial encounter for closed S22.051B Stable burst of T5-T6 vertebra, initial encounter for open S22.052A Unstable burst of T5-T6 vertebra, initial encounter for closed S22.052B Unstable burst of T5-T6 vertebra, initial encounter for open S22.058A Other of T5-T6 vertebra, initial encounter for closed S22.058B Other of T5-T6 vertebra, initial encounter for open S22.059A Unspecified of T5-T6 vertebra, initial encounter for closed S22.059B Unspecified of T5-T6 vertebra, initial encounter for open S22.060A Wedge compression of T7-T8 vertebra, initial encounter for closed S22.060B Wedge compression of T7-T8 vertebra, initial encounter for open S22.061A Stable burst of T7-T8 vertebra, initial encounter for closed S22.061B Stable burst of T7-T8 vertebra, initial encounter for open S22.062A Unstable burst of T7-T8 vertebra, initial encounter for closed S22.062B Unstable burst of T7-T8 vertebra, initial encounter for open S22.068A Other of T7-T8 thoracic vertebra, initial encounter for closed S22.068B Other of T7-T8 thoracic vertebra, initial encounter for open S22.069A Unspecified of T7-T8 vertebra, initial encounter for closed S22.069B Unspecified of T7-T8 vertebra, initial encounter for open S22.070A Wedge compression of T9-T10 vertebra, initial encounter for closed S22.070B Wedge compression of T9-T10 vertebra, initial encounter for open S22.071A Stable burst of T9-T10 vertebra, initial encounter for closed S22.071B Stable burst of T9-T10 vertebra, initial encounter for open S22.072A Unstable burst of T9-T10 vertebra, initial encounter for closed S22.072B Unstable burst of T9-T10 vertebra, initial encounter for open S22.078A Other of T9-T10 vertebra, initial encounter for closed S22.078B Other of T9-T10 vertebra, initial encounter for open S22.079A Unspecified of T9-T10 vertebra, initial encounter for closed S22.079B Unspecified of T9-T10 vertebra, initial encounter for open S22.080A Wedge compression of T11-T12 vertebra, initial encounter for closed S22.080B Wedge compression of T11-T12 vertebra, initial encounter for open S22.081A Stable burst of T11-T12 vertebra, initial encounter for closed S22.081B Stable burst of T11-T12 vertebra, initial encounter for open S22.082A Unstable burst of T11-T12 vertebra, initial encounter for closed S22.082B Unstable burst of T11-T12 vertebra, initial encounter for open S22.088A Other of T11-T12 vertebra, initial encounter for closed S22.088B Other of T11-T12 vertebra, initial encounter for open S22.089A Unspecified of T11-T12 vertebra, initial encounter for closed S22.089B Unspecified of T11-T12 vertebra, initial encounter for open S32.000A Wedge compression of unspecified lumbar vertebra, initial encounter for closed S32.000B Wedge compression of unspecified lumbar vertebra, initial encounter for open S32.001A Stable burst of unspecified lumbar vertebra, initial encounter for closed S32.001B Stable burst of unspecified lumbar vertebra, initial encounter for open S32.002A Unstable burst of unspecified lumbar vertebra, initial encounter for closed S32.002B Unstable burst of unspecified lumbar vertebra, initial encounter for open S32.008A Other of unspecified lumbar vertebra, initial encounter for closed S32.008B Other of unspecified lumbar vertebra, initial encounter for open S32.009A Unspecified of unspecified lumbar vertebra, initial encounter for closed S32.009B Unspecified of unspecified lumbar vertebra, initial encounter for open S32.010A Wedge compression of first lumbar vertebra, initial encounter for closed S32.010B Wedge compression of first lumbar vertebra, initial encounter for open S32.011A Stable burst of first lumbar vertebra, initial encounter for closed S32.011B Stable burst of first lumbar vertebra, initial encounter for open S32.012A Unstable burst of first lumbar vertebra, initial encounter for closed S32.012B Unstable burst of first lumbar vertebra, initial encounter for open S32.018A Other of first lumbar vertebra, initial encounter for closed S32.018B Other of first lumbar vertebra, initial encounter for open S32.019A Unspecified of first lumbar vertebra, initial encounter for closed Printed on 12/2/2016. Page 12 of 24

13 S32.019B S32.020A S32.020B S32.021A S32.021B S32.022A S32.022B S32.028A S32.028B S32.029A S32.029B S32.030A S32.030B S32.031A S32.031B S32.032A S32.032B S32.038A S32.038B S32.039A S32.039B S32.040A S32.040B S32.041A S32.041B S32.042A S32.042B S32.048A S32.048B S32.049A S32.049B S32.050A S32.050B S32.051A S32.051B S32.052A S32.052B S32.058A S32.058B S32.059A S32.059B S32.10XA S32.10XB S32.110A S32.110B S32.111A S32.111B S32.112A S32.112B S32.119A S32.119B S32.120A S32.120B S32.121A S32.121B S32.122A S32.122B Unspecified of first lumbar vertebra, initial encounter for open Wedge compression of second lumbar vertebra, initial encounter for closed Wedge compression of second lumbar vertebra, initial encounter for open Stable burst of second lumbar vertebra, initial encounter for closed Stable burst of second lumbar vertebra, initial encounter for open Unstable burst of second lumbar vertebra, initial encounter for closed Unstable burst of second lumbar vertebra, initial encounter for open Other of second lumbar vertebra, initial encounter for closed Other of second lumbar vertebra, initial encounter for open Unspecified of second lumbar vertebra, initial encounter for closed Unspecified of second lumbar vertebra, initial encounter for open Wedge compression of third lumbar vertebra, initial encounter for closed Wedge compression of third lumbar vertebra, initial encounter for open Stable burst of third lumbar vertebra, initial encounter for closed Stable burst of third lumbar vertebra, initial encounter for open Unstable burst of third lumbar vertebra, initial encounter for closed Unstable burst of third lumbar vertebra, initial encounter for open Other of third lumbar vertebra, initial encounter for closed Other of third lumbar vertebra, initial encounter for open Unspecified of third lumbar vertebra, initial encounter for closed Unspecified of third lumbar vertebra, initial encounter for open Wedge compression of fourth lumbar vertebra, initial encounter for closed Wedge compression of fourth lumbar vertebra, initial encounter for open Stable burst of fourth lumbar vertebra, initial encounter for closed Stable burst of fourth lumbar vertebra, initial encounter for open Unstable burst of fourth lumbar vertebra, initial encounter for closed Unstable burst of fourth lumbar vertebra, initial encounter for open Other of fourth lumbar vertebra, initial encounter for closed Other of fourth lumbar vertebra, initial encounter for open Unspecified of fourth lumbar vertebra, initial encounter for closed Unspecified of fourth lumbar vertebra, initial encounter for open Wedge compression of fifth lumbar vertebra, initial encounter for closed Wedge compression of fifth lumbar vertebra, initial encounter for open Stable burst of fifth lumbar vertebra, initial encounter for closed Stable burst of fifth lumbar vertebra, initial encounter for open Unstable burst of fifth lumbar vertebra, initial encounter for closed Unstable burst of fifth lumbar vertebra, initial encounter for open Other of fifth lumbar vertebra, initial encounter for closed Other of fifth lumbar vertebra, initial encounter for open Unspecified of fifth lumbar vertebra, initial encounter for closed Unspecified of fifth lumbar vertebra, initial encounter for open Unspecified of sacrum, initial encounter for closed Unspecified of sacrum, initial encounter for open Nondisplaced Zone I of sacrum, initial encounter for closed Nondisplaced Zone I of sacrum, initial encounter for open Minimally displaced Zone I of sacrum, initial encounter for closed Minimally displaced Zone I of sacrum, initial encounter for open Severely displaced Zone I of sacrum, initial encounter for closed Severely displaced Zone I of sacrum, initial encounter for open Unspecified Zone I of sacrum, initial encounter for closed Unspecified Zone I of sacrum, initial encounter for open Nondisplaced Zone II of sacrum, initial encounter for closed Nondisplaced Zone II of sacrum, initial encounter for open Minimally displaced Zone II of sacrum, initial encounter for closed Minimally displaced Zone II of sacrum, initial encounter for open Severely displaced Zone II of sacrum, initial encounter for closed Severely displaced Zone II of sacrum, initial encounter for open Printed on 12/2/2016. Page 13 of 24

14 S32.129A S32.129B S32.130A S32.130B S32.131A S32.131B S32.139A S32.139B S32.14XA S32.14XB S32.15XA S32.15XB S32.16XA S32.16XB S32.17XA S32.17XB S32.19XA S32.19XB S32.2XXA S32.2XXB T38.0X5A T38.0X5S T50.0X5A T50.0X5S Z09 Unspecified Zone II of sacrum, initial encounter for closed Unspecified Zone II of sacrum, initial encounter for open Nondisplaced Zone III of sacrum, initial encounter for closed Nondisplaced Zone III of sacrum, initial encounter for open Minimally displaced Zone III of sacrum, initial encounter for closed Minimally displaced Zone III of sacrum, initial encounter for open Unspecified Zone III of sacrum, initial encounter for closed Unspecified Zone III of sacrum, initial encounter for open Type 1 of sacrum, initial encounter for closed Type 1 of sacrum, initial encounter for open Type 2 of sacrum, initial encounter for closed Type 2 of sacrum, initial encounter for open Type 3 of sacrum, initial encounter for closed Type 3 of sacrum, initial encounter for open Type 4 of sacrum, initial encounter for closed Type 4 of sacrum, initial encounter for open Other of sacrum, initial encounter for closed Other of sacrum, initial encounter for open Fracture of coccyx, initial encounter for closed Fracture of coccyx, initial encounter for open Adverse effect of glucocorticoids and synthetic analogues, initial encounter Adverse effect of glucocorticoids and synthetic analogues, sequela Adverse effect of mineralocorticoids and their antagonists, initial encounter Adverse effect of mineralocorticoids and their antagonists, sequela Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm Z Encounter for screening for osteoporosis 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 Z79.83 Long term (current) use of bisphosphonates Z Acquired absence of ovaries, unilateral Z Acquired absence of ovaries, bilateral Z90.79 Acquired absence of other genital organ(s) Group 2 Paragraph: 77078, 77081, 77085, 76977, G0130: Group 2 : ICD-10 E21.0 Primary hyperparathyroidism E21.3 Hyperparathyroidism, unspecified E23.0 Hypopituitarism E24.0 Pituitary-dependent Cushing's disease E E24.4 Drug-induced Cushing's syndrome - Alcohol-induced pseudo-cushing's syndrome E E24.9 Other Cushing's syndrome - Cushing's syndrome, unspecified E Symptomatic premature menopause E Asymptomatic premature menopause E28.39 Other primary ovarian failure E34.2 Ectopic hormone secretion, not elsewhere classified E E89.41 Asymptomatic postprocedural ovarian failure - Symptomatic postprocedural ovarian failure M48.50XA Collapsed vertebra, not elsewhere classified, site unspecified, initial encounter for M48.51XA Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, initial encounter for M48.52XA Collapsed vertebra, not elsewhere classified, cervical region, initial encounter for Printed on 12/2/2016. Page 14 of 24