Knowledge Base Article

Remember when you were young and there were some positives in having a broken bone. You got to wear a flashy cast in the color of your choice and all your friends and family signed your cast. Another positive was that broken bones generally heal quickly and effectively in the young. Recovering from broken bones when you are older is harder and you could have lasting effects such as ongoing pain, especially if you have osteoporosis. According to the Centers for Disease Control (CDC) website, osteoporosis “affects about 25% (1 in 4) of women aged 65 and over and about 5% (1 in 20) of men aged 65 and over. Many people with osteoporosis do not know they have it until they break a bone. Screening is important to find these people before this happens, so they can take steps to decrease the effects of osteoporosis.” The website also contains steps you can take to improve your bone health and strengthen weak bones. The good news for older Americans is that Medicare covers bone mass measurements to screen for osteoporosis as one of their preventive services. This means the beneficiary co-pay and deductible are waived so Medicare bears all the cost of these screenings.

The coverage guidelines for bone mass measurements (BMM) can be found in Chapter 15 of the Medicare Benefits Policy Manual, section 80.5. Medicare pays for a screening BMM once every 2 years with a few exceptions for more frequent testing. Section 80.5.6 of the above referenced manual, states that Medicare covers the screening for the following:

1. A woman who has been determined by the physician or qualified nonphysician practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings.

NOTE: 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 or other qualified treating nonphysician practitioner from ordering a bone mass measurement for her. If a BMM 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.

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 3 months.
4. An individual with primary hyperparathyroidism.
5. An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy.

For healthcare providers, it is helpful to have a current list of the covered ICD-10 diagnosis codes. The BMM coverage is under National Coverage Determination (NCD) 150.3. CMS makes frequent updates to the NCD diagnosis codes as a result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. Providers should watch for these periodic updates through transmittals or you can find them listed by NCD number at this website –

https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html

Notice there were revisions to the NCD 150.3 as late as May 2019. You will need to open the transmittal and then locate the link within the transmittal to access the latest updates. There will be a spreadsheet for each updated NCD that includes the revisions and a complete list of covered codes.

Another thing to bear in mind about BMMs is the different CPT and diagnosis codes required for screening versus monitoring tests. From section 140.1 of the Medicare Claims Processing Manual, Chapter 13, contractors will pay claims for screening tests that contain CPT procedure code 77078, 77079, 77080, 77081, 77083, 76977 or G0130 when reported with an appropriate diagnosis code indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.

Dual-energy x-ray absorptiometry (axial) tests are covered when used to monitor FDA-approved osteoporosis drug therapy subject to the 2-year frequency standards. Contractors will pay claims for monitoring tests when coded as follows:

• Contains CPT procedure code 77080 or 77085, and
• Contains ICD-10- CM diagnosis code M81.0, M81.8, M81.6 or M94.9.

Single photon absorptiometry tests are not covered. Contractors will deny CPT procedure code 78350.

As you age take care of your bone health by taking your calcium and vitamin D, eating well, and doing strength exercises. As a Medicare provider, avoid denials by including the correct diagnosis codes on your claims for bone mass measurements.