- Email: [email protected]
Understanding the Bone Mass Measurement Act
Journal of Clinical Densitometry, vol. 2, no. 3, 211–217, Fall 1999 © Copyright 1999 by Humana Press Inc. All rights of any nature whatsoever reserved. 0169-4194/99/2:211–217/$11.75
Commentary
Understanding the Bone Mass Measurement Act Nelson B. Watts, MD Emory University, Atlanta, GA
Abstract The Bone Mass Measurement Act (BMMA) set forth regulations to provide for uniform coverage under Medicare Part B for bone mass measurements for services provided on or after July 1, 1998. The BMMA authorizes Medicare coverage of “medically necessary approved measurements” performed for a “qualified individual” who falls into at least one of five diagnostic categories: an estrogen-deficient woman at clinical risk for osteoporosis; an individual with vertebral abnormalities; an individual receiving long-term glucocorticoid (steroid) therapy; an individual with primary hyperparathyroidism; and an individual being monitored to assess the response to, or efficacy of, an approved osteoporosis drug therapy. Proper communication is essential for reimbursement. The tools for communication include Physician’s Current Procedural Terminology (CPT™), HCFA (Health Care Financing Administration) Common Procedure Coding System (HCPCS), the Medicare carrier’s local Medical Review Policy (LMRP), and the International Classification of Diseases, ninth revision (ICD-9). This article reviews the new regulations and the tools for communication. Key Words: Bone mass; densitometry; bone mineral density; Medicare; osteoporosis.
Section 4106(a)(1) of the Balanced Budget Act (BBA) of 1997 added section 1861(s)(15) to provide for uniform coverage under Medicare Part B for bone mass measurements for services provided on or after July 1, 1998. The implementation of this law was the responsibility of HCFA. The specifics (the Interim Final Rule) were published June 24, 1998 in the Federal Register (1). Although not specifically named as such, the just-cited legislation is often referred to as the Bone Mass Measurement Act (BMMA).
Introduction Prior to 1994, the Health Care Financing Administration (HCFA) had policies on some techniques for bone mass measurement (dual photon absorptiometry, single photon absorptiometry, and quantitative computed tomography) but no national policy on bone mass measurement by dual energy Xray absorptiometry (DXA). Local Medicare carriers set their own policies on reimbursement, coverage, and frequency for DXA. Beginning in 1994, HCFA developed standards for reimbursement for DXA, but local carriers still set policies on coverage and frequency.
Approved Indications for Bone Mass Measurement The BMMA authorizes Medicare coverage of “medically necessary approved measurements” performed for a “qualified individual” who falls into at least one of five diagnostic categories (see Table 1). These indications require explanation:
Received 04/15/99; Accepted 04/19/99. Address correspondence to Dr. Nelson B. Watts, The Emory Clinic, 1365 Clifton Road, NE, Atlanta, GA 30322. E-mail [email protected]
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Table 1 Indications for Bone Mass Measurement Provided Under the BMMAa 1. An estrogen-deficient woman at clinical risk for osteoporosis 2. An individual with vertebral abnormalities 3. An individual receiving long-term glucocorticoid (steroid) therapy 4. An individual with primary hyperparathyroidism 5. An individual being monitored to assess the response to, or efficacy of, an approved osteoporosis drug therapy a
See ref. 1.
• An “estrogen-deficient woman at clinical risk for osteoporosis” means “a woman who has been determined by her treating physician (or a qualified nonphysician practitioner)” to be “estrogendeficient and at clinical risk for osteoporosis, based on her medical history or other findings.” The regulations go on to say “it appears that not every woman who has been prescribed ERT (estrogen replacement therapy) may be receiving an `adequate’ dose … and, thus, may not be sufficiently protected against further bone loss. In view of the difficulty of trying to define the estrogendeficient statutory category precisely, we have decided in this interim final rule to allow a woman’s treating physician or other treating practitioner to determine whether she is estrogen-deficient and at clinical risk of osteoporosis, based on her medical history or other findings.” • The second indication requires radiographic evidence of “osteoporosis, low bone mass (osteopenia), or vertebral fracture.” • The third indication, corticosteroid therapy, specifies “an individual receiving glucocorticoid (steroid) therapy equivalent to 7.5 mg of prednisone, or greater, per day for more than 3 months, or if the expected duration of such therapy is more than 3 months.” • Primary hyperparathyroidism is straightforward. • The last indication requires “an approved osteoporosis drug therapy.” This could be interpreted to mean that coverage would be provided for anyone who is taking a drug that has been approved to
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treat osteoporosis (such as a man who is taking alendronate). More likely, this will be interpreted by carriers to mean only drugs that are used in their approved context (e.g., coverage will be provided for a woman with postmenopausal osteoporosis who is taking a drug that is approved to treat postmenopausal osteoporosis, but would not be provided for a woman who has glucocorticoidinduced osteoporosis who is taking the same drug or for a man who is taking the same drug). Because the determination of “estrogen deficient” and “at clinical risk for osteoporosis” are left to the provider, the BMMA makes it easy to justify coverage for women. Unfortunately, coverage for men is limited. Obviously, men cannot be covered under the first category (an estrogen-deficient woman at clinical risk for osteoporosis). Coverage is provided for men with vertebral abnormalities, men receiving long-term glucocorticoid therapy, and men with hyperparathyroidism. Whether coverage would be provided for men receiving treatment for osteoporosis would be at the discretion of the local carrier.
Frequency of Bone Mass Measurements Section 4106(a)(2) of the BBA requires the establishment of frequency standards governing the time period when “qualified individuals will be eligible to receive covered bone mass measurements.” The HCFA regulations state: In general, coverage for follow-up bone mass measurements will be limited to only one measurement every 2 years for beneficiaries who receive coverage of bone mass measurements. Follow-up bone mass measurements performed more frequently than once every 2 years [the regulations allow for testing every 23 months, which allows a one-month leeway] may be covered when medically necessary. Examples of situations where more frequent bone mass measurement procedures may be medically necessary include, but are not limited to, the following medical circumstances: (1) monitoring beneficiaries on long-term glucocorticoid (steroid) therapy of more than 3 months; and (2) allowing for a confirmatory baseline bone mass measurement (either central or peripheral) to permit monitoring of
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Bone Mass Measurement Act 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 performed using bone sonometry and monitoring is anticipated using bone densitometry, we will allow coverage of baseline measurement using bone densitometry).
The local carrier has some discretion regarding more frequent testing. The example given of a second test for monitoring when one was done for diagnosis using “a technique that is different” would probably apply to a peripheral DXA test done for diagnosis and a central DXA test done for monitoring. Although it is unlikely, this could be interpreted to mean that peripheral and central DXA use the same technique, and therefore this combination would not be covered. In addition to the covered examples, there are other clinical circumstances in which more frequent testing would be desirable. When a patient has a fracture despite being on therapy, there are two possible scenarios. One is that the patient has severe osteoporosis, has experienced an increase in bone mineral density with treatment, and has had a reduction in fracture risk. Had the patient not been on treatment, he or she would have fractured sooner or more extensively. A second possibility is that the patient had lost bone mass despite being on therapy. Bone density measurement should tell which of these scenarios applies. Another situation in which more frequent testing would be useful is the patient receiving treatment whose second test shows a significant loss and whose treatment is changed; waiting 2 yr more to see the effect of the new treatment would be undesirable, but coverage for testing earlier is up to the local carrier.
Communicating in Code For proper payment from Medicare and other carriers, it is necessary to communicate in code. The code books for this are Physician’s Current Procedural Terminology (CPT™),* HCFA (Health Care Financing Administration) Common Procedure Coding System (HCPCS), Medicare carrier local * CPT only © 1998 American Medical Association. All Rights Reserved.
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213 Medical Review Policy (LMRP), and the International Classification of Diseases, ninth revision (ICD-9). CPT and HPCS codes provide the carrier with a standardized description of what was done. Modifiers allow providers to indicate that a service was altered in some way from the stated CPT/HCPCS description. Medicare carrier–specific LMRP coding and billing guidelines can supercede the traditional coding rules. ICD-9 codes are used as a determination of a condition, disease, or syndrome; give an indication as to why a test was done; and are often required by carriers to indicate the “medical necessity” of the test or service being billed. Appendix 1 lists sources for these publications. CPT was developed by the American Medical Association and is updated yearly. It contains 5-digit codes for radiologic services (7xxxx), laboratory tests (8xxxx), evaluation and management (“E&M”) services such as consultations and office visits (9xxxx), surgery, procedures, and so on (2). CPT also contains a list of 2-digit numerical modifiers. Table 2 shows the CPT codes for bone densitometry. The CPT code for central DXA (or DEXA) is 76075. Before January 1, 1998, CPT defined 76075 as “Dual energy x-ray absorptiometry (DEXA), bone density study (3). This allowed spine and hip measurement to be billed separately. For example, a patient having a hip and spine study could be billed as 76075 for the hip and 76075-ZF for the spine (modifier -ZF† from HCPCS[4] indicates different anatomical sites). For several years, Medicare had a single fee regardless of how many sites were measured, although most carriers paid for each measurement. Effective January 1, 1998, the CPT definition of 76075 was changed to “bone density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)” (5). This means that now only one procedure may be billed, regardless of how many measurements are done. DXA may be billed as single fee or as technical and professional components. Modifier -26 (from CPT) indicates the professional component; modifier -TC (from HPCS) indicates the technical component (this technical component must be an institutional charge, not billed separately by the † HCPCS modifiers are 2-letter codes, whereas CPT modifiers are 2-digit codes.
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Table 2 Procedure Codes for Bone Densitometrya 76075
76070
Dual energy x-ray absorptiometry (DEXA), bone density study, one or more sites; axial skeleton (eg, hips, pelvis, spine) Computerized tomography bone mineral density study, one or more sites
PERIPHERAL SITES (radius, wrist, heel) 76070–52 Computerized tomography bone mineral density study, one or more sites [modifier 52 indicates a reduced service] 76076 Dual energy x-ray absorptiometry (DEXA), bone density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel) 76078 Radiographic absorptiometry (photodensitometry) G0130 Single energy x-ray absorptiometry (SEXA) (use the “G” code for Medicare; use 76499 [unlisted diagnostic radiologic procedure]) for private insurer 76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method a Physician’s Current Procedural Terminology (CPT™), 1999, Standard Edition, copyright American Medical Association, Chicago, IL, used with permission (2). CPT only © 1998 American Medical Association. All Rights Reserved.
physician). The complete code for billing the professional component is 76075–26. The complete code for billing the technical component is 76075-TC. The provider is obligated to inform the patient if there is a possibility that a test will not be covered. In the case of bone densitometry, coverage might be denied if the patient does not meet the frequency requirement of his or her diagnosis is not “covered” in the Medicare carrier’s LMRP. The patient should be asked to sign a waiver indicating that he or she has been informed of this. Modifier -GA (from HCPCS) indicates that a Medicare waiver has been signed and is on file. A copy of the waiver should also be given to the patient. A claim should be filed with Medicare. If the claim is rejected, the patient should be billed for the test. Proper coding for a central DXA study for a Medicare patient who has signed a waiver is 76075-GA. Electronic claims processing allows for only one modifier to be submitted. In the case of multiple modifiers, it is necessary to submit a paper bill on an Journal of Clinical Densitometry
HCFA 1500 claim form. Modifier -99 (from CPT) indicates circumstances when two or more modifiers are needed to describe a service. For example, to bill a DXA professional component (–26) when the patient has signed a waiver (–GA), the claim would look as follows: 76075-99 dual energy x-ray absorptiometry no charge 76705-26 professional component $XX.XX 76075-GA waiver on file no charge
The International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM), provides diagnosis codes. The ninth revision was done in 1977 but is updated yearly. The Clinical Modification was added by US National Center for Health Statistics. Since 1988, ICD-9 codes have been required on all claims submitted to Medicare Part B. ICD-9 contains numerical codes for diseases, a series of “V” codes for factors influencing health status and contact with health services, and a series of “E” codes for causes of external injury and poisoning that also include lists of medications (6). Appendix 2 provides examples of these codes that may be pertinent for patients requiring bone densitometry. Despite the intention of the BMMA to provide national standards, there are still regional differences. Part of the reason for these differences is the fact that several of the covered indications do not have discrete ICD-9 codes. This means that each carrier must determine the ICD-9 codes it will accept for each of the five covered indications (LMRP). Table 3 presents the ICD-9 codes for Medicare in Georgia. Appendix 3 presents Internet Web sites for some other Medicare carriers, whose ICD-9 codes are available.
Summary Medicare now covers bone densitometry for five specific conditions: estrogen-deficient women at risk for osteoporosis, patients with vertebral abnormalities, patients with hyperparathyroidism, patients requiring treatment with corticosteroids, and patients being monitored while receiving therapy with an approved drug. Repeat studies will be covered every 2 yr, more frequently for patients treated with corticosteroids and perhaps under other circumstances. Volume 2, 1999
Bone Mass Measurement Act
Table 3 ICD-9 Codes That Provide Medicare Coverage for Bone Densitometry in Georgia • Indication 1, an estrogen deficient woman at clinical risk for osteoporosis: 256.2 postablative ovarian failure or 256.3 other ovarian failure or 627.2 menopausal or female climacteric states. • Indication 2, an individual with vertebral abnormalities: 733.90 disorder of bone and cartilage, unspecified [osteopenia] or 733.13 pathologic fracture of vertebrae. • Indication 3, an individual receiving long-term glucocorticoid (steroid) therapy: 733.09 osteoporosis, drug induced and E932.0 adrenal cortical steroids. • Indication 4, an individual with primary hyperparathyroidism: 252.0 hyperparathyroidism. • Indication 5, an individual being monitored to assess the response to an approved drug: 733.00–733.09 osteoporosis and V67.59 following other treatment, other.
References 1. Department of Health and Human Services: Medicare coverage of and payment for bone mass measurements. 1998 Fed Reg 63:34,320–34,328. 2. American Medical Association. 1999 Physician’s Current Procedural Terminology, 1999 (CPT-99). American Medical Association, Chicago. 3. American Medical Association. 1997 Physician’s Current Procedural Terminology, 1997 (CPT). American Medical Association, Chicago. 4. Medicode, Inc. 1999 HCFA Common Procedure Coding System (HCPS). Medicode, Salt Lake City. 5. American Medical Association. 1998 Physician’s Current Procedural Terminology, 1998 (CPT-98). American Medical Association, Chicago. 6. Medicode, Inc. 1999 International Classification of Diseases (ICD-9). Medicode, Salt Lake City.
Appendix 1. Source of Publications Copies of the Federal Register may be obtained as follows: • By mail: Send your request to: New Orders, Superintendent of Documents, P. O. Box 371954, Journal of Clinical Densitometry
215 Pittsburgh, PA 15250-7954. Ask for the July 24, 1998 issue. Enclose a check or money order payable to the Superintendent of Documents, or enclose your Visa or Master Card number and expiration date. The cost for each copy is $8. • By telephone: Call the order desk at (202) 5121800 or fax to (202) 512-2250. Give your Visa or Master Card number and expiration date. The cost for each copy is $8. • At libraries: You can view and photocopy the Federal Register at most libraries designated as Federal Depository Libraries and at many other public and academic libraries throughout the country that receive the Federal Register. • On the World Wide Web: The Superintendent of Documents home page address is http://www.access.gpo.gov/su_docs/ Physician’s Current Procedural Terminology (CPT™), 1999 Standard Edition may be purchased from the American Medical Association by calling (800) 621-8335. HCFA (Health Care Financing Administration) Common Procedure Coding System (HCPCS) and International Classification of Diseases, ninth revision (ICD-9-CM) are available from Medicode, Inc. 5225 Wiley Post Way, Suite 500, Salt Lake City, UT 84116-2889; telephone (801) 536-1000, fax (801) 536-1001.
Appendix 2. Selected ICD-9 Codes That Relate to Osteoporosis and Metabolic Bone Diseases* OSTEOPOROSIS 733.00 osteoporosis, unspecified (wedging of vertebra NOS [not otherwise specified]) 733.01 senile osteoporosis; postmenopausal 733.02 idiopathic osteoporosis 733.03 disuse osteoporosis 733.09 other [osteoporosis]; drug induced; use additional E code to identify drug (E932.0 indicates corticosteroids) OSTEOPOROTIC FRACTURES [Pathologic fracture is used to distinguish osteoporotic fractures from traumatic fractures] 733.10 pathologic fracture, unspecified site 733.11 pathologic fracture of humerus Volume 2, 1999
216 733.12 733.13 733.14 733.15
pathologic fracture of distal radius and ulna pathologic fracture of vertebrae pathologic fracture of neck of femur pathologic fracture of other specified part of femur 733.16 pathologic fracture of tibia or fibula 733.19 pathologic fracture of other specified site CODES FOR SIGNS, SYMPTOMS, COMPLICATIONS, AND RISK FACTORS 307.1 anorexia nervosa; eating disturbance NOS 369.9 unspecified visual loss 724.5 backache, unspecified; vertebrogenic (pain) syndrome 737.41 kyphosis 737.42 lordosis 737.43 scoliosis 781.9 other symptoms involving nervous and musculoskeletal systems; abnormal posture 787.1 heartburn CODES FOR METABOLIC BONE DISEASES 588.0 renal osteodystrophy 592.0 calculus of kidney; excludes uric acid nephrolithiasis 731.0 osteitis deformans without mention of bone tumor; Paget’s disease 733.29 cyst of bone; other; fibrous dysplasia of bone, monostotic 756.51 osteogenesis imperfecta 756.54 polyostotic fibrous dysplasia of bone PARATHYROID HORMONE, VITAMIN D 252.0 hyperparathyroidism, excludes secondary hyperparathyroidism (of renal origin) 252.1 hypoparathyroidism 268.2 osteomalacia 269.3 mineral deficiency, not elsewhere classified; [dietary calcium deficiency] 275.40 unspecified disorder of calcium metabolism 275.41 hypocalcemia 275.42 hypercalcemia 275.8 other specified disorders of mineral metabolism 278.4 hypervitaminosis D 588.8 secondary hyperparathyroidism (of renal origin)
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Watts GONADAL DYSFUNCTION 256.2 postablative ovarian failure 256.3 other ovarian failure; premature menopause NOS, primary ovarian failure 256.8 other ovarian dysfunction 256.9 unspecified ovarian dysfunction 257.1 postablative testicular hypofunction 257.2 other testicular hypofunction 257.9 unspecified testicular dysfunction 627.2 menopause or female climacteric state; symptoms such as flushing, sleeplessness … associated with menopause 627.8 other specified menopausal and postmenopausal disorders 627.9 other unspecified menopausal and postmenopausal disorders MISCELLANEOUS 272.7 lipidoses; Gaucher’s disease 275.2 disorders of magnesium metabolism; hypermagnesemia, hypomagnesemia 275.3 disorders of phosphorous metabolism 276.2 cystic fibrosis 277.0 eating disorder 793.7 nonspecific abnormal findings on radiological and other examination of … [the] musculoskeletal system 794.6 nonspecific abnormal results of … other endocrine function study “V” CODES, FACTORS INFLUENCING HEALTH STATUS AND CONTACT WITH HEALTH SERVICES V07.4 postmenopausal hormone replacement therapy V07.8 other specified prophylactic measure V17.8 family history of certain chronic disabling diseases, other musculoskeletal disease V58.69 long-term (current) use of other medications; high-risk medications V65.43 other counseling, not elsewhere classified; counseling on injury prevention V67.59 following other treatment, other; excludes long-term (current) drug use V71.8 observation for specified suspected conditions V71.9 observation for unspecified suspected conditions
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Bone Mass Measurement Act V82.8 special screening for other conditions, other specified conditions “E” CODES: CAUSES OF EXTERNAL INJURY AND POISONING E932.0 adrenal cortical steroids E932.2 ovarian hormones and synthetic substitutes E932.7 thyroid and thyroid derivatives E933.1 antineoplastic and immunosuppressive drugs E933.5 vitamins, not elsewhere classified; vitamin D E934.2 anticoagulants E936.1 hydantoin derivatives; phenytoin E937.9 sedatives and hypnotics, unspecified; sleeping pills E939.x psychotropic agents E944.3 saluretics; benzothiadiazides, chlorthiazide group E944.4 other diuretics; furosemide *
From ref. 6.
Appendix 3. Medicare Carrier Web Sites HCFA’s Medicare home page is http://www.hcfa.gov/medicare/medicare.htm. A listing of telephone and fax numbers for Medicare carriers by state is posted at http://www.xact.org/partbcar.html.
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217 Web address
Location
http://www.gamedicare.com http://www.empiremedicare.com http://lamedicare.com http://www.medicare-link.com
Georgia New York Louisiana Connecticut, Minnesota, Mississippi, Virginia http://www.nationwide-medicare.com Ohio, West Virginia http://www.xact.org Pennsylvania, New Jersey http://www.pgba.com/palmetto/main.nsf South Carolina http://www.the-medicare.com/provider_info.asp D.C. area, Delaware, Maryland, Texas http://www.triples-med.org/ Puerto Rico http://www.bcbsnd.com/medweb/ Alaska, Arizona, Colorado, lowa, Nevada, North Dakota, Oregon, South Dakota, Wyoming http://www.wpsic.com/medicare/whoarewe.html Wisconsin http://www.cignamedicare.com/med_partb Idaho, North Carolina, Tennessee
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Commentary
Understanding the Bone Mass Measurement Act Nelson B. Watts, MD Emory University, Atlanta, GA
Abstract The Bone Mass Measurement Act (BMMA) set forth regulations to provide for uniform coverage under Medicare Part B for bone mass measurements for services provided on or after July 1, 1998. The BMMA authorizes Medicare coverage of “medically necessary approved measurements” performed for a “qualified individual” who falls into at least one of five diagnostic categories: an estrogen-deficient woman at clinical risk for osteoporosis; an individual with vertebral abnormalities; an individual receiving long-term glucocorticoid (steroid) therapy; an individual with primary hyperparathyroidism; and an individual being monitored to assess the response to, or efficacy of, an approved osteoporosis drug therapy. Proper communication is essential for reimbursement. The tools for communication include Physician’s Current Procedural Terminology (CPT™), HCFA (Health Care Financing Administration) Common Procedure Coding System (HCPCS), the Medicare carrier’s local Medical Review Policy (LMRP), and the International Classification of Diseases, ninth revision (ICD-9). This article reviews the new regulations and the tools for communication. Key Words: Bone mass; densitometry; bone mineral density; Medicare; osteoporosis.
Section 4106(a)(1) of the Balanced Budget Act (BBA) of 1997 added section 1861(s)(15) to provide for uniform coverage under Medicare Part B for bone mass measurements for services provided on or after July 1, 1998. The implementation of this law was the responsibility of HCFA. The specifics (the Interim Final Rule) were published June 24, 1998 in the Federal Register (1). Although not specifically named as such, the just-cited legislation is often referred to as the Bone Mass Measurement Act (BMMA).
Introduction Prior to 1994, the Health Care Financing Administration (HCFA) had policies on some techniques for bone mass measurement (dual photon absorptiometry, single photon absorptiometry, and quantitative computed tomography) but no national policy on bone mass measurement by dual energy Xray absorptiometry (DXA). Local Medicare carriers set their own policies on reimbursement, coverage, and frequency for DXA. Beginning in 1994, HCFA developed standards for reimbursement for DXA, but local carriers still set policies on coverage and frequency.
Approved Indications for Bone Mass Measurement The BMMA authorizes Medicare coverage of “medically necessary approved measurements” performed for a “qualified individual” who falls into at least one of five diagnostic categories (see Table 1). These indications require explanation:
Received 04/15/99; Accepted 04/19/99. Address correspondence to Dr. Nelson B. Watts, The Emory Clinic, 1365 Clifton Road, NE, Atlanta, GA 30322. E-mail [email protected]
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Table 1 Indications for Bone Mass Measurement Provided Under the BMMAa 1. An estrogen-deficient woman at clinical risk for osteoporosis 2. An individual with vertebral abnormalities 3. An individual receiving long-term glucocorticoid (steroid) therapy 4. An individual with primary hyperparathyroidism 5. An individual being monitored to assess the response to, or efficacy of, an approved osteoporosis drug therapy a
See ref. 1.
• An “estrogen-deficient woman at clinical risk for osteoporosis” means “a woman who has been determined by her treating physician (or a qualified nonphysician practitioner)” to be “estrogendeficient and at clinical risk for osteoporosis, based on her medical history or other findings.” The regulations go on to say “it appears that not every woman who has been prescribed ERT (estrogen replacement therapy) may be receiving an `adequate’ dose … and, thus, may not be sufficiently protected against further bone loss. In view of the difficulty of trying to define the estrogendeficient statutory category precisely, we have decided in this interim final rule to allow a woman’s treating physician or other treating practitioner to determine whether she is estrogen-deficient and at clinical risk of osteoporosis, based on her medical history or other findings.” • The second indication requires radiographic evidence of “osteoporosis, low bone mass (osteopenia), or vertebral fracture.” • The third indication, corticosteroid therapy, specifies “an individual receiving glucocorticoid (steroid) therapy equivalent to 7.5 mg of prednisone, or greater, per day for more than 3 months, or if the expected duration of such therapy is more than 3 months.” • Primary hyperparathyroidism is straightforward. • The last indication requires “an approved osteoporosis drug therapy.” This could be interpreted to mean that coverage would be provided for anyone who is taking a drug that has been approved to
Journal of Clinical Densitometry
treat osteoporosis (such as a man who is taking alendronate). More likely, this will be interpreted by carriers to mean only drugs that are used in their approved context (e.g., coverage will be provided for a woman with postmenopausal osteoporosis who is taking a drug that is approved to treat postmenopausal osteoporosis, but would not be provided for a woman who has glucocorticoidinduced osteoporosis who is taking the same drug or for a man who is taking the same drug). Because the determination of “estrogen deficient” and “at clinical risk for osteoporosis” are left to the provider, the BMMA makes it easy to justify coverage for women. Unfortunately, coverage for men is limited. Obviously, men cannot be covered under the first category (an estrogen-deficient woman at clinical risk for osteoporosis). Coverage is provided for men with vertebral abnormalities, men receiving long-term glucocorticoid therapy, and men with hyperparathyroidism. Whether coverage would be provided for men receiving treatment for osteoporosis would be at the discretion of the local carrier.
Frequency of Bone Mass Measurements Section 4106(a)(2) of the BBA requires the establishment of frequency standards governing the time period when “qualified individuals will be eligible to receive covered bone mass measurements.” The HCFA regulations state: In general, coverage for follow-up bone mass measurements will be limited to only one measurement every 2 years for beneficiaries who receive coverage of bone mass measurements. Follow-up bone mass measurements performed more frequently than once every 2 years [the regulations allow for testing every 23 months, which allows a one-month leeway] may be covered when medically necessary. Examples of situations where more frequent bone mass measurement procedures may be medically necessary include, but are not limited to, the following medical circumstances: (1) monitoring beneficiaries on long-term glucocorticoid (steroid) therapy of more than 3 months; and (2) allowing for a confirmatory baseline bone mass measurement (either central or peripheral) to permit monitoring of
Volume 2, 1999
Bone Mass Measurement Act 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 performed using bone sonometry and monitoring is anticipated using bone densitometry, we will allow coverage of baseline measurement using bone densitometry).
The local carrier has some discretion regarding more frequent testing. The example given of a second test for monitoring when one was done for diagnosis using “a technique that is different” would probably apply to a peripheral DXA test done for diagnosis and a central DXA test done for monitoring. Although it is unlikely, this could be interpreted to mean that peripheral and central DXA use the same technique, and therefore this combination would not be covered. In addition to the covered examples, there are other clinical circumstances in which more frequent testing would be desirable. When a patient has a fracture despite being on therapy, there are two possible scenarios. One is that the patient has severe osteoporosis, has experienced an increase in bone mineral density with treatment, and has had a reduction in fracture risk. Had the patient not been on treatment, he or she would have fractured sooner or more extensively. A second possibility is that the patient had lost bone mass despite being on therapy. Bone density measurement should tell which of these scenarios applies. Another situation in which more frequent testing would be useful is the patient receiving treatment whose second test shows a significant loss and whose treatment is changed; waiting 2 yr more to see the effect of the new treatment would be undesirable, but coverage for testing earlier is up to the local carrier.
Communicating in Code For proper payment from Medicare and other carriers, it is necessary to communicate in code. The code books for this are Physician’s Current Procedural Terminology (CPT™),* HCFA (Health Care Financing Administration) Common Procedure Coding System (HCPCS), Medicare carrier local * CPT only © 1998 American Medical Association. All Rights Reserved.
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213 Medical Review Policy (LMRP), and the International Classification of Diseases, ninth revision (ICD-9). CPT and HPCS codes provide the carrier with a standardized description of what was done. Modifiers allow providers to indicate that a service was altered in some way from the stated CPT/HCPCS description. Medicare carrier–specific LMRP coding and billing guidelines can supercede the traditional coding rules. ICD-9 codes are used as a determination of a condition, disease, or syndrome; give an indication as to why a test was done; and are often required by carriers to indicate the “medical necessity” of the test or service being billed. Appendix 1 lists sources for these publications. CPT was developed by the American Medical Association and is updated yearly. It contains 5-digit codes for radiologic services (7xxxx), laboratory tests (8xxxx), evaluation and management (“E&M”) services such as consultations and office visits (9xxxx), surgery, procedures, and so on (2). CPT also contains a list of 2-digit numerical modifiers. Table 2 shows the CPT codes for bone densitometry. The CPT code for central DXA (or DEXA) is 76075. Before January 1, 1998, CPT defined 76075 as “Dual energy x-ray absorptiometry (DEXA), bone density study (3). This allowed spine and hip measurement to be billed separately. For example, a patient having a hip and spine study could be billed as 76075 for the hip and 76075-ZF for the spine (modifier -ZF† from HCPCS[4] indicates different anatomical sites). For several years, Medicare had a single fee regardless of how many sites were measured, although most carriers paid for each measurement. Effective January 1, 1998, the CPT definition of 76075 was changed to “bone density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)” (5). This means that now only one procedure may be billed, regardless of how many measurements are done. DXA may be billed as single fee or as technical and professional components. Modifier -26 (from CPT) indicates the professional component; modifier -TC (from HPCS) indicates the technical component (this technical component must be an institutional charge, not billed separately by the † HCPCS modifiers are 2-letter codes, whereas CPT modifiers are 2-digit codes.
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Table 2 Procedure Codes for Bone Densitometrya 76075
76070
Dual energy x-ray absorptiometry (DEXA), bone density study, one or more sites; axial skeleton (eg, hips, pelvis, spine) Computerized tomography bone mineral density study, one or more sites
PERIPHERAL SITES (radius, wrist, heel) 76070–52 Computerized tomography bone mineral density study, one or more sites [modifier 52 indicates a reduced service] 76076 Dual energy x-ray absorptiometry (DEXA), bone density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel) 76078 Radiographic absorptiometry (photodensitometry) G0130 Single energy x-ray absorptiometry (SEXA) (use the “G” code for Medicare; use 76499 [unlisted diagnostic radiologic procedure]) for private insurer 76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method a Physician’s Current Procedural Terminology (CPT™), 1999, Standard Edition, copyright American Medical Association, Chicago, IL, used with permission (2). CPT only © 1998 American Medical Association. All Rights Reserved.
physician). The complete code for billing the professional component is 76075–26. The complete code for billing the technical component is 76075-TC. The provider is obligated to inform the patient if there is a possibility that a test will not be covered. In the case of bone densitometry, coverage might be denied if the patient does not meet the frequency requirement of his or her diagnosis is not “covered” in the Medicare carrier’s LMRP. The patient should be asked to sign a waiver indicating that he or she has been informed of this. Modifier -GA (from HCPCS) indicates that a Medicare waiver has been signed and is on file. A copy of the waiver should also be given to the patient. A claim should be filed with Medicare. If the claim is rejected, the patient should be billed for the test. Proper coding for a central DXA study for a Medicare patient who has signed a waiver is 76075-GA. Electronic claims processing allows for only one modifier to be submitted. In the case of multiple modifiers, it is necessary to submit a paper bill on an Journal of Clinical Densitometry
HCFA 1500 claim form. Modifier -99 (from CPT) indicates circumstances when two or more modifiers are needed to describe a service. For example, to bill a DXA professional component (–26) when the patient has signed a waiver (–GA), the claim would look as follows: 76075-99 dual energy x-ray absorptiometry no charge 76705-26 professional component $XX.XX 76075-GA waiver on file no charge
The International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM), provides diagnosis codes. The ninth revision was done in 1977 but is updated yearly. The Clinical Modification was added by US National Center for Health Statistics. Since 1988, ICD-9 codes have been required on all claims submitted to Medicare Part B. ICD-9 contains numerical codes for diseases, a series of “V” codes for factors influencing health status and contact with health services, and a series of “E” codes for causes of external injury and poisoning that also include lists of medications (6). Appendix 2 provides examples of these codes that may be pertinent for patients requiring bone densitometry. Despite the intention of the BMMA to provide national standards, there are still regional differences. Part of the reason for these differences is the fact that several of the covered indications do not have discrete ICD-9 codes. This means that each carrier must determine the ICD-9 codes it will accept for each of the five covered indications (LMRP). Table 3 presents the ICD-9 codes for Medicare in Georgia. Appendix 3 presents Internet Web sites for some other Medicare carriers, whose ICD-9 codes are available.
Summary Medicare now covers bone densitometry for five specific conditions: estrogen-deficient women at risk for osteoporosis, patients with vertebral abnormalities, patients with hyperparathyroidism, patients requiring treatment with corticosteroids, and patients being monitored while receiving therapy with an approved drug. Repeat studies will be covered every 2 yr, more frequently for patients treated with corticosteroids and perhaps under other circumstances. Volume 2, 1999
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Table 3 ICD-9 Codes That Provide Medicare Coverage for Bone Densitometry in Georgia • Indication 1, an estrogen deficient woman at clinical risk for osteoporosis: 256.2 postablative ovarian failure or 256.3 other ovarian failure or 627.2 menopausal or female climacteric states. • Indication 2, an individual with vertebral abnormalities: 733.90 disorder of bone and cartilage, unspecified [osteopenia] or 733.13 pathologic fracture of vertebrae. • Indication 3, an individual receiving long-term glucocorticoid (steroid) therapy: 733.09 osteoporosis, drug induced and E932.0 adrenal cortical steroids. • Indication 4, an individual with primary hyperparathyroidism: 252.0 hyperparathyroidism. • Indication 5, an individual being monitored to assess the response to an approved drug: 733.00–733.09 osteoporosis and V67.59 following other treatment, other.
References 1. Department of Health and Human Services: Medicare coverage of and payment for bone mass measurements. 1998 Fed Reg 63:34,320–34,328. 2. American Medical Association. 1999 Physician’s Current Procedural Terminology, 1999 (CPT-99). American Medical Association, Chicago. 3. American Medical Association. 1997 Physician’s Current Procedural Terminology, 1997 (CPT). American Medical Association, Chicago. 4. Medicode, Inc. 1999 HCFA Common Procedure Coding System (HCPS). Medicode, Salt Lake City. 5. American Medical Association. 1998 Physician’s Current Procedural Terminology, 1998 (CPT-98). American Medical Association, Chicago. 6. Medicode, Inc. 1999 International Classification of Diseases (ICD-9). Medicode, Salt Lake City.
Appendix 1. Source of Publications Copies of the Federal Register may be obtained as follows: • By mail: Send your request to: New Orders, Superintendent of Documents, P. O. Box 371954, Journal of Clinical Densitometry
215 Pittsburgh, PA 15250-7954. Ask for the July 24, 1998 issue. Enclose a check or money order payable to the Superintendent of Documents, or enclose your Visa or Master Card number and expiration date. The cost for each copy is $8. • By telephone: Call the order desk at (202) 5121800 or fax to (202) 512-2250. Give your Visa or Master Card number and expiration date. The cost for each copy is $8. • At libraries: You can view and photocopy the Federal Register at most libraries designated as Federal Depository Libraries and at many other public and academic libraries throughout the country that receive the Federal Register. • On the World Wide Web: The Superintendent of Documents home page address is http://www.access.gpo.gov/su_docs/ Physician’s Current Procedural Terminology (CPT™), 1999 Standard Edition may be purchased from the American Medical Association by calling (800) 621-8335. HCFA (Health Care Financing Administration) Common Procedure Coding System (HCPCS) and International Classification of Diseases, ninth revision (ICD-9-CM) are available from Medicode, Inc. 5225 Wiley Post Way, Suite 500, Salt Lake City, UT 84116-2889; telephone (801) 536-1000, fax (801) 536-1001.
Appendix 2. Selected ICD-9 Codes That Relate to Osteoporosis and Metabolic Bone Diseases* OSTEOPOROSIS 733.00 osteoporosis, unspecified (wedging of vertebra NOS [not otherwise specified]) 733.01 senile osteoporosis; postmenopausal 733.02 idiopathic osteoporosis 733.03 disuse osteoporosis 733.09 other [osteoporosis]; drug induced; use additional E code to identify drug (E932.0 indicates corticosteroids) OSTEOPOROTIC FRACTURES [Pathologic fracture is used to distinguish osteoporotic fractures from traumatic fractures] 733.10 pathologic fracture, unspecified site 733.11 pathologic fracture of humerus Volume 2, 1999
216 733.12 733.13 733.14 733.15
pathologic fracture of distal radius and ulna pathologic fracture of vertebrae pathologic fracture of neck of femur pathologic fracture of other specified part of femur 733.16 pathologic fracture of tibia or fibula 733.19 pathologic fracture of other specified site CODES FOR SIGNS, SYMPTOMS, COMPLICATIONS, AND RISK FACTORS 307.1 anorexia nervosa; eating disturbance NOS 369.9 unspecified visual loss 724.5 backache, unspecified; vertebrogenic (pain) syndrome 737.41 kyphosis 737.42 lordosis 737.43 scoliosis 781.9 other symptoms involving nervous and musculoskeletal systems; abnormal posture 787.1 heartburn CODES FOR METABOLIC BONE DISEASES 588.0 renal osteodystrophy 592.0 calculus of kidney; excludes uric acid nephrolithiasis 731.0 osteitis deformans without mention of bone tumor; Paget’s disease 733.29 cyst of bone; other; fibrous dysplasia of bone, monostotic 756.51 osteogenesis imperfecta 756.54 polyostotic fibrous dysplasia of bone PARATHYROID HORMONE, VITAMIN D 252.0 hyperparathyroidism, excludes secondary hyperparathyroidism (of renal origin) 252.1 hypoparathyroidism 268.2 osteomalacia 269.3 mineral deficiency, not elsewhere classified; [dietary calcium deficiency] 275.40 unspecified disorder of calcium metabolism 275.41 hypocalcemia 275.42 hypercalcemia 275.8 other specified disorders of mineral metabolism 278.4 hypervitaminosis D 588.8 secondary hyperparathyroidism (of renal origin)
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Watts GONADAL DYSFUNCTION 256.2 postablative ovarian failure 256.3 other ovarian failure; premature menopause NOS, primary ovarian failure 256.8 other ovarian dysfunction 256.9 unspecified ovarian dysfunction 257.1 postablative testicular hypofunction 257.2 other testicular hypofunction 257.9 unspecified testicular dysfunction 627.2 menopause or female climacteric state; symptoms such as flushing, sleeplessness … associated with menopause 627.8 other specified menopausal and postmenopausal disorders 627.9 other unspecified menopausal and postmenopausal disorders MISCELLANEOUS 272.7 lipidoses; Gaucher’s disease 275.2 disorders of magnesium metabolism; hypermagnesemia, hypomagnesemia 275.3 disorders of phosphorous metabolism 276.2 cystic fibrosis 277.0 eating disorder 793.7 nonspecific abnormal findings on radiological and other examination of … [the] musculoskeletal system 794.6 nonspecific abnormal results of … other endocrine function study “V” CODES, FACTORS INFLUENCING HEALTH STATUS AND CONTACT WITH HEALTH SERVICES V07.4 postmenopausal hormone replacement therapy V07.8 other specified prophylactic measure V17.8 family history of certain chronic disabling diseases, other musculoskeletal disease V58.69 long-term (current) use of other medications; high-risk medications V65.43 other counseling, not elsewhere classified; counseling on injury prevention V67.59 following other treatment, other; excludes long-term (current) drug use V71.8 observation for specified suspected conditions V71.9 observation for unspecified suspected conditions
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Bone Mass Measurement Act V82.8 special screening for other conditions, other specified conditions “E” CODES: CAUSES OF EXTERNAL INJURY AND POISONING E932.0 adrenal cortical steroids E932.2 ovarian hormones and synthetic substitutes E932.7 thyroid and thyroid derivatives E933.1 antineoplastic and immunosuppressive drugs E933.5 vitamins, not elsewhere classified; vitamin D E934.2 anticoagulants E936.1 hydantoin derivatives; phenytoin E937.9 sedatives and hypnotics, unspecified; sleeping pills E939.x psychotropic agents E944.3 saluretics; benzothiadiazides, chlorthiazide group E944.4 other diuretics; furosemide *
From ref. 6.
Appendix 3. Medicare Carrier Web Sites HCFA’s Medicare home page is http://www.hcfa.gov/medicare/medicare.htm. A listing of telephone and fax numbers for Medicare carriers by state is posted at http://www.xact.org/partbcar.html.
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217 Web address
Location
http://www.gamedicare.com http://www.empiremedicare.com http://lamedicare.com http://www.medicare-link.com
Georgia New York Louisiana Connecticut, Minnesota, Mississippi, Virginia http://www.nationwide-medicare.com Ohio, West Virginia http://www.xact.org Pennsylvania, New Jersey http://www.pgba.com/palmetto/main.nsf South Carolina http://www.the-medicare.com/provider_info.asp D.C. area, Delaware, Maryland, Texas http://www.triples-med.org/ Puerto Rico http://www.bcbsnd.com/medweb/ Alaska, Arizona, Colorado, lowa, Nevada, North Dakota, Oregon, South Dakota, Wyoming http://www.wpsic.com/medicare/whoarewe.html Wisconsin http://www.cignamedicare.com/med_partb Idaho, North Carolina, Tennessee
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