Cpt code for bone density of hips only

Transcription

1 Cpt code for bone density of hips only Enter a location: Find a13 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 They are listed in the Category Search on the Medical Policy search page X-RAY XR Cervical 6+ Views (Davis Series) X-RAY XR Cervical 2-3 Views - Neck pain. Monitoring patients on long-term glucocorticoid (steroid) therapy of more than 3 months; and. 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. 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. The below code would not be paid when billing with cpt code 77080, use correct modifier. - Neck pain w/ upper extremity radicular symptoms w/ suspected cervical instability. In addition to gender and estrogendeficiency, 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. Steinberg (1995) evaluated the safety and effectiveness of core decompression in the treatment of AVN of the femoral head. All patients with AVN of the femoral head, stages I to IVA, were included regardless of the cause of the necrosis. A total of 300 hips were available for analysis. The follow-up ranged from 2 to 12 years. Main outcome measures included antero-posterior and lateral radiographs, taken immediately before surgery and at the final follow-up, clinical hip evaluation according to the Harris scoring system, and the need for total hip replacement. One patient sustained a subcapital fracture 1 month after surgery due to a fall. There was 1 case of non-fatal pulmonary embolism, 1 case of pneumonia, and 1 case of thrombo-phlebitis of the thigh. A total of 46 % of operatively managed hips showed no radiographical progression of disease compared with only 19 % of non-operatively managed hips. Moreover, 35 % of the operatively managed hips required total hip replacement compared with 77 % of non-operatively managed hips. The results in hips with early (stages I and II) AVN were only slightly better than those of hips with advanced (stages III and IVA) disease. However, the results in hips with small areas of necrosis in both stages I and II were much better than those with larger lesions; only 7 % of the former group required total hip replacement after decompression and cancellous bone grafting. The authors concluded that core decompression with cancellous bone grafting is a safe and effective procedure for the treatment of early AVN of the femoral head. Results with this form of treatment are considerably better than those obtained in patients treated non-operatively. Late/post-collapse (stage III or higher; when X-ray changes have occurred) avascular necrosis of

2 the hip. - Back pain/lower extremity radicular symptoms, especially when position dependent. 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) CPT codes and 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. 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. Medicare may cover a bone mass measurement for a patient once every 2 years. However, if medically necessary, Medicare may cover a bone mass measurement for a patient more frequently than every 2 years. Examples of situations where more frequent bone mass measurements procedures may be medically necessary include, but are not limited to, the following medical circumstances: Medicare claim address, phone numbers, payor id - revised list. Core decompression of the hip is usually employed before collapse and fracture of the femoral head and/or neck to delay or avoid reconstructive surgery of the affected joint. It is generally carried out to preserve the function and the structure of the hip as well as to relieve pain associated with AVN. Core decompression entails repair of the necrotic site by coring, followed by filling the cored area with a bone graft, which is optional. A lateral trochanteric approach is used in this procedure: an 8-mm to 10-mm cylindrical core of bone is removed from the antero-lateral segment of the femoral head, which creates an open cylindrical channel. This open channel serves to relieve pressure. The open channel may be filled with either a vascularized or a nonvascularized bone graft. The former is used to aid in the ingrowth of vascular cellular tissue into the necrotic area; thus enhancing re-vascularization, which may arrest the progression of the necrosis. The latter is used to provide structural stability to the hip during the healing process. There is adequate evidence that core decompression is effective in treating early stages (I or II) of AVN of the hip. CPT Code Peripheral Ultrasound Bone Mineral Density MRI MR Cervical without contrast with Flexion & Extension. - Chest 1 View Chest 2 Views Chest Minimum 4 Views Chest Special Views Ribs Unilateral 2 Views Ribs Unilateral 2 Views with PA CXR Ribs Bilateral 3 Views Sternum Minimum 2 Views Sternoclavicular Joints 3 Views Abdomen or KUB or 1 View Abdomen 2 View Complete or Flat and Upright Acute Abdomen Series + PA CXR 3 Views Pelvis 1 or 2 Views Pelvis Minimum 3 Views Sacrum & Coccyx Minimum 2 Views Sacroiliac Joints 3+ Views Finger(s) Minimum 2 Views Hand 2 Views Hand Minimum 3 Views Wrist 2 Views Wrist Minimum 3 Views Forearm 2 Views Upper Extremity Infant (up to 364 days old) Minimum 2 Views Elbow 2 Views Elbow Minimum 3 Views Humerus Minimum 2 Views Shoulder 1 View Shoulder Minimum 2 Views Acromioclavicular Joints Bilateral Clavicle Complete Scapula Complete Toe(s) Minimum 2 Views Foot 2 Views Foot Minimum 3 Views Calcaneus (Heel) Minimum 2 Views Ankle 2 Views Ankle Minimum 3 Views Tibia & Fibula 2 Views Lower Extremity Infant (up to 364 days old) 2+ Views Knee 1 or 2 Views Knee 3 Views Knee 4 or More Views Both Knees Standing AP Bone Age Studies Bone Length Studies Osseous Complete (Bone Survey) Mandible. - Back pain with or without leg pain, especially if symptoms increase with bending. Autologous bone marrow mononuclear cells/bone marrow concentrate/bone marrow stem cells. Aetna considers core decompression experimental and investigational for the treatment of the following indications (not an all-inclusive list) because its effectiveness for these indications has not been established. Bone density measurement is not a covered Medicare benefit when

3 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. Screening of men greater than 70 years of age ( Note: covered for members with preventive services benefits only); or. Dual-energy radiographic (x-ray) absorptiometry scans of the femur have a precision error from 0.5 % to 3 %. Precision error is the variability in the measurements occurring with repeated measurements of the same object. A technique's precision is critical for serial measurements that correctly document bone loss over time. Factors such as patient positioning, calibration and standardization procedures, and differences in operator technique can result in large measurement variations. The precision of measurements is reduced outside of the controlled conditions of a clinical trial setting. Dual photon absorptiometry measures trabecular bone but costs more, takes longer, and the patient must lie down; apparent changes in serial DPA results must be carefully interpreted because the aging of the Gd-153 source can result in an apparent increase in bone mineral content. Ultrasound technology to measure and interpret bone density at peripheral sites by any method is considered investigational. ICD-9-CM code should be reported to indicate osteopenia, (only when billing DXA), when used to follow treatment with FDA approved osteoporosis medications. Is reasonable and necessary for diagnosing and treating the beneficiary's condition. Kullenberg and Falch (2003) compared the prevalence of osteoporosis (using a T-score threshold of -2.5 for heel measurements) by DXL technology with that obtained by DXA measurements at the femoral neck, spine and forearm. Aetna considers simultaneous axial (central) and appendicular (peripheral) bone mass measurements medically necessary only in the following limited circumstances:. 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). Monitoring of individuals on long-term glucocorticoid (steroid) therapy or anticonvulsant therapy of more than 3 months duration; or. Individuals being monitored to assess the response to or efficacy of osteoporosis drug therapy (only dual-energy x- ray absorptiometry is considered medically necessary for this indication); or. Ultrasound bone mineral density studies (e.g., Achilles + Bone Sonometer, Sahara, SoundScan). 1. A woman who has been determined by her physician to be estrogen-deficient and at clinical risk for osteoporosis. CT SCAN AND CTA CPT codes list Note: Examples of vertebral fracture assessment application packages that have received 510(k) marketing clearance are the Instant Vertebral Assessment (IVA) (Hologic, Inc.) and Dual Energy Vertebral Assessment (DVA) (previously known as Lateral Vertebral Assessment (LVA) (GE Lunar Medical Systems). The following methods are established procedures of bone mass measurements of the axial or appendicular (peripheral) skeleton:. Peripheral measurement of BMD may be considered medically necessary:. Upper w/o contrast Upper w/o & w/ contrast Lower w/o contrast Lower w/o & w/ contrast CPT 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. Initial or repeat bone mineral density (BMD) measurement is not indicated unless the results will influence treatment decisions. However, the clinical literature on the accuracy and precision of bone density measurement does not support a recommendation for annual screening. Erlichman and Holohan (1996) reviewed the literature on commonly used bone densitometry techniques, including DEXA. They found that, although reviews of recent studies report DEXA accuracy error from 3 to 6 %, other data indicate that DEXA accuracy error of ashed bone specimens of 9 %. (Measurements obtained by

4 densitometers are compared with an independent standard measurement of bone mass, such as ashed bone sections. The accuracy error is determined by how much the measurement varies from this accepted or "true" value.). The U.S. Preventive Services Task Force updated its 2002 recommendation on screening for osteoporosis (USPSTF, 2011). The USPSTF evaluated evidence on the diagnostic accuracy of risk assessment instruments for osteoporosis and fractures, the performance of DEXA and peripheral bone measurement tests in predicting fractures, the harms of screening for osteoporosis, and the benefits and harms of drug therapy for osteoporosis in women and men. The USPSTF recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year old white woman who has no additional risk factors (Grade B recommendation). The USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men DUAL-ENERGY X- RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE). 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. A BMM is covered if the beneficiary meets at least one of the following conditions:. Monitoring patients on long-term glucocorticoid (steroid) therapy of more than 3 months; and. Medicare will cover DEXA bone mass measurement once every 2 years on a person who falls into 1 out of the 5 Following categories:. >/MediaBox[ ] /Contents 5 0 R/Group /Tabs/S/StructParents 0>> endobj 5 0 obj. 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). Chest/Thorax w/o contrast Chest/Thorax w/ contrast Chest/Thorax w/o & w/ contrast Initial or repeat bone mineral density (BMD) measurement is not indicated unless the results will influence treatment decisions. Earlier technologies, such as single and dual photon absorptiometry (CPT code or 78351), are no longer used.guidelines. * Men age about whom there is a concern based on their risk factors;. Screening individuals who are at low risk for osteoporosis is considered not medically necessary. Single photon absorptiometry (SPA), CPT code (effective 01/01/2007). * 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 be 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

5 places of service for reimbursement: office (11), mobile (15), independent clinic (49), federally qualified health centers (50) and rural health clinics (72). Medicare Fee for Office Visit CPT Codes - CPT Code 99213, 99214, 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. 2. This service must be furnished by a qualified supplier or provider of such services under the appropriate level of physician supervision as defined in CFR (b); 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. 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. Bone Mass Measurement (BMM) studies are radiologic, radioisotopic, or other procedures used to:. 1. Monitoring individuals on long-term glucocorticoid (steroid) therapy of more than 3 months duration; or.