New Guidelines for the Bone Density Test

Jurisdiction 11 Part B

Bone Mass Measurement (BMM) Billing Guidelines

Bone Mass Measurement (BMM) is covered by Medicare under the following conditions:

1. Must be ordered by the physician or qualified non-physician practitioner (NPP) who is treating the beneficiary and uses the results in the management of the patient
2. Is performed under the appropriate physician supervision as defined in 42 CFR 410.32(b)
3. Is reasonable and necessary for diagnosing and treating the beneficiary's condition
4. In the case of an individual with a diagnosis of osteoporosis being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy, if it is performed with a dual energy X-ray absorptiometry system (axial skeleton) (77080)
5. For a confirmatory baseline BMM prior to osteoporosis treatment that is performed with a dual-energy X-ray absorptiometry system (axial skeleton), if the initial BMM was not performed by a dual-energy X-ray absorptiometry system (axial skeleton). A baseline BMM is not covered if the initial BMM was performed by a dual-energy X-ray absorptiometry system (axial skeleton).

A screening BMM is covered if the beneficiary meets at least one of the following conditions:

1. The woman has been determined by the physician or qualified NPP treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings
2. An individual with vertebral abnormalities as demonstrated by an X-ray to be indicative of osteoporosis, osteopenia or vertebral fracture
3. 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 three months
4. An individual with primary hyperparathyroidism

Medicare pays for a screening BMM once every two years (e.g., at least 23 months have passed since the month the last covered BMM was performed).
To report a screening BMM submit the following:

• CPT Codes 77078, 77079*, 77080, 77081, 77083*, 76977 or G0130 (NOTE*: CPT Codes 77079 and 77083 will no longer be valid as of January 1, 2012)
• One of the following ICD-9 codes listed below submitted as the principal diagnosis code:
  • 252.01, 255.0, 256.2, 256.31, 256.39, 256.9, 259.3, 627.0, 627.1, 627.2, 627.3, 627.4, 627.8, 627.9, 733.13, 733.90, 756.51, 758.6, 793.7, 805.00, 805.01, 805.02, 805.03, 805.04, 805.05, 805.06, 805.07, 805.08, 805.10, 805.11, 805.12, 805.13, 805.14, 805.15, 805.16, 805.17, 805.18, 805.2, 805.3, 805.4, 805.5, 805.6, 805.7, 805.8, 805.9, 806.00, 806.01, 806.02, 806.03, 806.04, 806.05, 806.06, 806.07, 806.08, 806.09, 806.10, 806.11, 806.12, 806.13, 806.14, 806.15, 806.16, 806.17, 806.18, 806.19, 806.20, 806.21, 806.22, 806.23, 806.24, 806.25, 806.26, 806.27, 806.28, 806.29, 806.30, 806.31, 806.32, 806.33, 806.34, 806.35, 806.36, 806.37, 806.38, 806.39, 806.4, 806.5, 806.60, 806.61, 806.62, 806.69, 806.70, 806.71, 806.72, 806.79, 806.8 or 806.9
• 'V' codes may be listed on the claim as the principal diagnosis code:
  • V45.77, V49.81, V58.65 or V82.81
• To report a monitoring BMM for a patient after a diagnosis of osteoporosis has been established, report one of the following ICD-9 codes with CPT Code 77080:
  • 255.0, 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, V58.65, V58.69 or V67.51

The following BMMs are non-covered under Medicare because they are not considered reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act (the Act):

• Single photon absorptiometry – CPT Code 78350 (effective January 1, 2007)
• Dual photon absorptiometry – CPT Code 78351

References

• CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, §§80.5-80.5.7 (PDF, 1.18 MB)
• CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 13, §§140-140.4 (PDF, 368 KB)