Local Coverage Article for Bone Mass Measurements Coverage - 2012 CPT Updates (A51577) Contractor Information Contractor Name Noridian Administrative Services, LLC opens in new window Contractor Number 03201 Contractor Type MAC - Part A Article Information General Information Article ID Number A51577 Article Type Article Key Article No Article Title Bone Mass Measurements Coverage - 2012 CPT Updates AMA CPT / ADA CDT Copyright Statement CPT only copyright 2002-2012 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. 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-2010 are trademarks of the American Dental Association. Primary Geographic Jurisdiction opens in new window Montana Original Article Effective Date 02/05/2009 Article Revision Effective Date 02/27/2012 Article Text This article from "Medicare A News," Issue 2096 dated October 19, 2011 and "Medicare B News", Issue 273 dated October 6, 2011 is being updated and reprinted to ensure that the NAS provider and supplier community has access to recent publications that contain the most current, accurate and effective information available. This article contains instructions for coding medical necessity in accordance with both the National Coverage Determinations (NCD) and Centers for Medicare and Medicaid Services (CMS) instructions on bone mass measurements (BMM), which includes the 2012 code updates. These coding guidelines are not intended to replace any found in the ICD-9-CM Official Guidelines for Coding and Reporting, nor are they intended to provide guidance on when a condition should be coded. Rather, providers should use this article in conjunction with the UB-04 Data Specifications Manual and the ICD-9-CM Official Guidelines for Coding and Reporting. BMM screening may, for specific beneficiaries, be completed once every 2 years (at least 23 months have passed since the month the last covered BMM was performed). In order for the screening to be covered, the beneficiary must meet at least one of the following conditions as listed in Publication 100-02, Medicare Benefit Policy Manual; Chapter 15, Section 80.5.6. Printed on 2/13/2013. Page 1 of 6
Coding Information CPT/HCPCS Codes CPT 76977, 77078, 77080, 77081, or HCPC G0130: A woman who has been determined by the physician or qualified non-physician practitioner (NPP) treating her to be estrogen-deficient and at clinical risk for osteoporosis based on her medical history and other findings. An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture. An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than 3 months. An individual with primary hyperparathyroidism. ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETATION, PERIPHERAL SITE(S), ANY 76977 METHOD COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, 77078 HIPS, PELVIS, SPINE) DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; AXIAL 77080 SKELETON (EG, HIPS, PELVIS, SPINE) DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; 77081 APPENDICULAR SKELETON (PERIPHERAL) (EG, RADIUS, WRIST, HEEL) SINGLE ENERGY X-RAY ABSORPTIOMETRY (SEXA) BONE DENSITY STUDY, ONE OR MORE SITES; G0130 APPENDICULAR SKELETON (PERIPHERAL) (EG, RADIUS, WRIST, HEEL) ICD-9 Codes that are Covered Diagnosis codes that support coverage of CPT 76977, 77078, 77080, 77081, or HCPC G0130: 252.00 HYPERPARATHYROIDISM, UNSPECIFIED 252.01 PRIMARY HYPERPARATHYROIDISM 252.02 SECONDARY HYPERPARATHYROIDISM, NON-RENAL 252.08 OTHER HYPERPARATHYROIDISM 253.2 PANHYPOPITUITARISM 253.7 IATROGENIC PITUITARY DISORDERS 255.0 CUSHING'S SYNDROME 255.3 OTHER CORTICOADRENAL OVERACTIVITY 256.2 POSTABLATIVE OVARIAN FAILURE 256.31 PREMATURE MENOPAUSE 256.39 OTHER OVARIAN FAILURE 256.4 POLYCYSTIC OVARIES 256.8 OTHER OVARIAN DYSFUNCTION 256.9 UNSPECIFIED OVARIAN DYSFUNCTION 259.3 ECTOPIC HORMONE SECRETION NOT ELSEWHERE CLASSIFIED 275.5 HUNGRY BONE SYNDROME 588.0 RENAL OSTEODYSTROPHY 588.81 SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN) 588.89 OTHER SPECIFIED DISORDERS RESULTING FROM IMPAIRED RENAL FUNCTION 626.0 ABSENCE OF MENSTRUATION 627.0 PREMENOPAUSAL MENORRHAGIA 627.1 POSTMENOPAUSAL BLEEDING 627.2 SYMPTOMATIC MENOPAUSAL OR FEMALE CLIMACTERIC STATES 627.3 POSTMENOPAUSAL ATROPHIC VAGINITIS 627.4 SYMPTOMATIC STATES ASSOCIATED WITH ARTIFICIAL MENOPAUSE 627.8 OTHER SPECIFIED MENOPAUSAL AND POSTMENOPAUSAL DISORDERS 627.9 UNSPECIFIED MENOPAUSAL AND POSTMENOPAUSAL DISORDER 720.0 ANKYLOSING SPONDYLITIS 733.00 OSTEOPOROSIS UNSPECIFIED 733.01 SENILE OSTEOPOROSIS 733.02 IDIOPATHIC OSTEOPOROSIS 733.12 PATHOLOGICAL FRACTURE OF DISTAL RADIUS AND ULNA Printed on 2/13/2013. Page 2 of 6
733.13 PATHOLOGICAL FRACTURE OF VERTEBRAE 733.14 PATHOLOGICAL FRACTURE OF NECK OF FEMUR 733.90 DISORDER OF BONE AND CARTILAGE UNSPECIFIED 737.19 OTHER KYPHOSIS ACQUIRED 737.29 OTHER LORDOSIS ACQUIRED 737.30 SCOLIOSIS (AND KYPHOSCOLIOSIS) IDIOPATHIC 758.6 GONADAL DYSGENESIS 805.00 CLOSED FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL 805.01 CLOSED FRACTURE OF FIRST CERVICAL VERTEBRA 805.02 CLOSED FRACTURE OF SECOND CERVICAL VERTEBRA 805.03 CLOSED FRACTURE OF THIRD CERVICAL VERTEBRA 805.04 CLOSED FRACTURE OF FOURTH CERVICAL VERTEBRA 805.05 CLOSED FRACTURE OF FIFTH CERVICAL VERTEBRA 805.06 CLOSED FRACTURE OF SIXTH CERVICAL VERTEBRA 805.07 CLOSED FRACTURE OF SEVENTH CERVICAL VERTEBRA 805.08 CLOSED FRACTURE OF MULTIPLE CERVICAL VERTEBRAE 805.10 OPEN FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL 805.11 OPEN FRACTURE OF FIRST CERVICAL VERTEBRA 805.12 OPEN FRACTURE OF SECOND CERVICAL VERTEBRA 805.13 OPEN FRACTURE OF THIRD CERVICAL VERTEBRA 805.14 OPEN FRACTURE OF FOURTH CERVICAL VERTEBRA 805.15 OPEN FRACTURE OF FIFTH CERVICAL VERTEBRA 805.16 OPEN FRACTURE OF SIXTH CERVICAL VERTEBRA 805.17 OPEN FRACTURE OF SEVENTH CERVICAL VERTEBRA 805.18 OPEN FRACTURE OF MULTIPLE CERVICAL VERTEBRAE 805.2 CLOSED FRACTURE OF DORSAL (THORACIC) VERTEBRA WITHOUT SPINAL CORD INJURY 805.3 OPEN FRACTURE OF DORSAL (THORACIC) VERTEBRA WITHOUT SPINAL CORD INJURY 805.4 CLOSED FRACTURE OF LUMBAR VERTEBRA WITHOUT SPINAL CORD INJURY 805.5 OPEN FRACTURE OF LUMBAR VERTEBRA WITHOUT SPINAL CORD INJURY 805.6 CLOSED FRACTURE OF SACRUM AND COCCYX WITHOUT SPINAL CORD INJURY 805.7 OPEN FRACTURE OF SACRUM AND COCCYX WITHOUT SPINAL CORD INJURY 805.8 CLOSED FRACTURE OF UNSPECIFIED PART OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY 805.9 OPEN FRACTURE OF UNSPECIFIED PART OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY 806.00 CLOSED FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY 806.01 CLOSED FRACTURE OF C1-C4 LEVEL WITH COMPLETE LESION OF CORD 806.02 CLOSED FRACTURE OF C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME 806.03 CLOSED FRACTURE OF C1-C4 LEVEL WITH CENTRAL CORD SYNDROME 806.04 CLOSED FRACTURE OF C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 806.05 CLOSED FRACTURE OF C5-C7 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY 806.06 CLOSED FRACTURE OF C5-C7 LEVEL WITH COMPLETE LESION OF CORD 806.07 CLOSED FRACTURE OF C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME 806.08 CLOSED FRACTURE OF C5-C7 LEVEL WITH CENTRAL CORD SYNDROME 806.09 CLOSED FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 806.10 OPEN FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY 806.11 OPEN FRACTURE OF C1-C4 LEVEL WITH COMPLETE LESION OF CORD 806.12 OPEN FRACTURE OF C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME 806.13 OPEN FRACTURE OF C1-C4 LEVEL WITH CENTRAL CORD SYNDROME 806.14 OPEN FRACTURE OF C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 806.15 OPEN FRACTURE OF C5-C7 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY 806.16 OPEN FRACTURE OF C5-C7 LEVEL WITH COMPLETE LESION OF CORD 806.17 OPEN FRACTURE OF C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME 806.18 OPEN FRACTURE OF C5-C7 LEVEL WITH CENTRAL CORD SYNDROME 806.19 OPEN FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 806.20 CLOSED FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY 806.21 CLOSED FRACTURE OF T1-T6 LEVEL WITH COMPLETE LESION OF CORD 806.22 CLOSED FRACTURE OF T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME 806.23 CLOSED FRACTURE OF T1-T6 LEVEL WITH CENTRAL CORD SYNDROME 806.24 CLOSED FRACTURE OF T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 806.25 CLOSED FRACTURE OF T7-T12 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY Printed on 2/13/2013. Page 3 of 6
806.26 CLOSED FRACTURE OF T7-T12 LEVEL WITH COMPLETE LESION OF CORD 806.27 CLOSED FRACTURE OF T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME 806.28 CLOSED FRACTURE OF T7-T12 LEVEL WITH CENTRAL CORD SYNDROME 806.29 CLOSED FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 806.30 OPEN FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY 806.31 OPEN FRACTURE OF T1-T6 LEVEL WITH COMPLETE LESION OF CORD 806.32 OPEN FRACTURE OF T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME 806.33 OPEN FRACTURE OF T1-T6 LEVEL WITH CENTRAL CORD SYNDROME 806.34 OPEN FRACTURE OF T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 806.35 OPEN FRACTURE OF T7-T12 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY 806.36 OPEN FRACTURE OF T7-T12 LEVEL WITH COMPLETE LESION OF CORD 806.37 OPEN FRACTURE OF T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME 806.38 OPEN FRACTURE OF T7-T12 LEVEL WITH CENTRAL CORD SYNDROME 806.39 OPEN FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 806.4 CLOSED FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY 806.5 OPEN FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY 806.60 CLOSED FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY 806.61 CLOSED FRACTURE OF SACRUM AND COCCYX WITH COMPLETE CAUDA EQUINA LESION 806.62 CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER CAUDA EQUINA INJURY 806.69 CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY 806.70 OPEN FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY 806.71 OPEN FRACTURE OF SACRUM AND COCCYX WITH COMPLETE CAUDA EQUINA LESION 806.72 OPEN FRACTURE OF SACRUM AND COCCYX WITH OTHER CAUDA EQUINA INJURY 806.79 OPEN FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY 806.8 CLOSED FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY 806.9 OPEN FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY V07.4 HORMONE REPLACEMENT THERAPY (POSTMENOPAUSAL) V07.51 USE OF SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS) V07.52 USE OF AROMATASE INHIBITORS V07.59 USE OF OTHER AGENTS AFFECTING ESTROGEN RECEPTORS AND ESTROGEN LEVELS V13.51 PERSONAL HISTORY OF PATHOLOGIC FRACTURE V49.81 ASYMPTOMATIC POSTMENOPAUSAL STATUS (AGE-RELATED) (NATURAL) V58.65 LONG-TERM (CURRENT) USE OF STEROIDS V87.43 PERSONAL HISTORY OF ESTROGEN THERAPY V87.45 PERSONAL HISTORY OF SYSTEMIC STEROID THERAPY ICD-9 Codes that are Not Covered CPT 77080 only: An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy. Confirming baseline BMM or BMMs to permit monitoring beneficiaries in the future. (NOTE: Providers may code screening, V82.81, or other codes as appropriate. However, only the following codes will support medical necessity for this NCD.) In List A: The following "V" code support coverage for CPT 77080 only (and no other procedure including 76977, 77078, 77080, 77081, or G0130), when combined with one of the diagnoses in LIST B which follows below: LIST A V58.68 LONG TERM (CURRENT) USE OF BISPHOSPHONATES And one of the following: LIST B 255.0 CUSHING'S SYNDROME Printed on 2/13/2013. Page 4 of 6
733.00 OSTEOPOROSIS UNSPECIFIED 733.01 SENILE OSTEOPOROSIS 733.02 IDIOPATHIC OSTEOPOROSIS 733.03 DISUSE OSTEOPOROSIS 733.09 OTHER OSTEOPOROSIS 733.90 DISORDER OF BONE AND CARTILAGE UNSPECIFIED Other Information Other Comments When medically necessary, coverage of more frequent BMMs may be indicated. Examples include, but are not limited to the following medical circumstances: Monitoring beneficiaries on long-term glucocorticoid (steroid) therapy of more than 3 months; (CPT 76977, 77078, 77080, 77081, or HCPCS G0130). In order for the BMM to be covered, the testing must be completed under the following conditions found in chapter 15, section 80.5.4 of Publication 100-02, Medicare Benefit Policy Manual: The physician or qualified NPP who is treating the beneficiary must order the BMM as well as determine the appropriate BMM to be used. The BMM must be performed under the appropriate level of physician supervision as defined in 42 CFR 410.32(b). The BMM is reasonable and necessary for the diagnosing and treating the condition of a beneficiary who meets the conditions described above. In the case of BMM for the monitoring of the effectiveness of drug therapy for osteoporosis, coverage is limited to Dual-energy X-ray Absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine); CPT 77080. In the case of a confirmatory baseline BMM, coverage is limited to a BMM completed by DEXA system (axial skeleton) for an individual and above conditions are met as well as the initial BMM was not performed using a DEXA system (axial skeleton). Coding Revision History Effective Date: 01/01/2012 Changes Implemented: CPT Codes 77079 and 77083 are removed from this revised article because they are deleted for 2012. Effective Date: 10/01/2011 Changes Implemented: ICD-9-CM V58.68 is a new code for 2011-2012 and is added to List A only. The following ICD-9-CM codes, 733.03, 733.09, 737.10, 737.11, 737.12 737.20, 737.21, and 737.22 were deleted for CPT Codes 76977, 77078, 77079, 77080, 77081, 77083 or G0130. Also deleted for List A are V58.69, V67.51 and V67.59 for 77080. References: IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 13, Section 140; IOM Medicare Benefit Policy Manual Publication 100-02, Chapter 15, Section 80.5; Transmittal 69 and 70 Change Request 5521 dated May 11, 2007; Transmittal 1416, CR 5847 dated January 18, 2008; IOM National Coverage Determinations Manual Publication 100-03, Chapter 1, Section 150.3; 42 CFR 410.31 and 42CFR 410.32; CPT manual, HCPCS manual and ICD-9-CM Manual. Printed on 2/13/2013. Page 5 of 6
Effective Date: January 1, 2012 Revision History Explanation 11/21/2011 - The following CPT/HCPCS codes were deleted: 77079 was deleted from Group 1 77083 was deleted from Group 1 02/27/2012 - In accordance with Section 911 of the Medicare Modernization Act of 2003,The contractor numbers 02101, 02201, 02301 and 02401 were added to this article as the claims processing for the states of AK, ID, OR and WA are transitioned to MAC JF. All Versions Updated on 02/25/2012 with effective dates 02/27/2012 - N/A Read the Article Disclaimer opens in new window Printed on 2/13/2013. Page 6 of 6