Billing and Coding: Bone Mass Measurement

This article gives guidance for billing, coding, and other guidelines in
relation to local coverage policy L36460-Bone Mass Measurement.



**General Guidelines for Claims submitted to Part A or Part B MAC:**

Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare. For services requiring a referring/ordering physician, the
name and NPI of the referring/ordering physician must be reported on the
claim. A claim submitted without a valid ICD-10-CM diagnosis code will be
returned to the provider as an incomplete claim under Section 1833(e) of the
Social Security Act. The diagnosis code(s) must best describe the patient's
condition for which the service was performed. For diagnostic tests, report
the result of the test if known; otherwise the symptoms prompting the
performance of the test should be reported.



**Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines**

An ABN may be used for services which are likely to be non-covered, whether
for medical necessity or for other reasons. Refer to CMS Publication 100-04,
Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with
modifier -GA, -GX, -GY, or -GZ, as appropriate.

The -GA modifier ("Waiver of Liability Statement Issued as Required by Payer
Policy") should be used when physicians, practitioners, or suppliers want to
indicate that they anticipate that Medicare will deny a specific service as
not reasonable and necessary and they do have an ABN signed by the beneficiary
on file. Modifier GA applies only when services will be denied under
reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e),
or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC
systems will automatically deny services billed with modifier GA. An ABN, Form
CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts
responsibility for payment. The -GA modifier may also be used on assigned
claims when a patient refuses to sign the ABN and the latter is properly
witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the
date of the ABN is required.



Modifier GX ("Notice of Liability Issued, Voluntary Under Payer Policy")
should be used when the beneficiary has signed an ABN, and a denial is
anticipated based on provisions other than medical necessity, such as
statutory exclusions of coverage or technical issues. An ABN is not required
for these denials, but if non-covered services are reported with modifier GX,
will automatically be denied services.



The -GZ modifier should be used when physicians, practitioners, or suppliers
want to indicate that they expect that Medicare will deny an item or service
as not reasonable and necessary and they have not had an ABN signed by the
beneficiary. If the service is statutorily non-covered, or without a benefit
category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN
is not required for these denials, and the limitation of liability does not
apply for beneficiaries. Services with modifier GY will automatically deny.

**Documentation Requirements**

The patient's medical record should include but is not limited to:

  * The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  * Relevant medical history
  * Results of pertinent tests/procedures
  * Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)+



Earlier technologies, such as _single and dual photon absorptiometry_ ( CPT
code 78350 or 78351), are no  
longer used.

**Limitations:  
  
** 1\. Tests not ordered by the physician/qualified non-physician
practitioner, who is treating the beneficiary, are not reasonable and
necessary.  
  
2\. Medicare reimbursement for an initial bone mass measurement may be allowed
only once, regardless of  
sites studied (e.g., if the spine and hip are studied, CPT code 77080 should
be billed only once).  
  
3\. It is not medically necessary to perform more than one type of BMM test in
any individual, unless a  
DXA confirmatory test is performed as a baseline for future monitoring (see
Indications #7 and #8).  
  
4\. It is not medically necessary to have both peripheral and axial BMM tests
performed on the same day.  
  
5\. Medicare will not reimburse BMM tests performed by a second provider, when
a test has already been  
performed within the defined coverage period, as stated above, unless as
confirmatory testing for future  
monitoring. Beneficiaries must authorize providers to obtain prior test
results. If unsuccessful efforts to  
obtain prior test results from another provider are documented, new tests may
be considered for  
reimbursement.  
  
6\. _Single and dual photon absorptiometry,_ CPT code 78350 and 78351, are
non-covered services.  
  
7\. Bone mass measurement is not covered under the portable x-ray benefit and
will be denied when  
performed by a portable x-ray supplier. Transportation charges for BMM testing
are not covered.  
  
8\. Bone mass measurement tests provided without an accompanying
interpretation and report, as part of  
the test, will be denied as not medically necessary. The report must be
separate and distinct from an evaluation and management note/record.  
  
9\. CPT code 77082 is considered by Medicare to represent vertebral fracture
assessment only. Because  
code 77082 does not represent a bone density study, it should NOT be billed
for screening. This code  
may be billed when medically necessary (i.e. when a vertebral fracture
assessment is required).  
Symptoms should be present and documented, and it should be anticipated that
the results of the test  
will be used in the management of the patient.  
  
 **Other Comments:**  
  
For Claims submitted to the Part A MAC: This coverage determination also
applies within states outside the  
primary geographic jurisdiction with facilities that have nominated CGS
Administrators to process their claims.  
  
Bill type codes only apply to providers who bill these services to the Part A
MAC. Bill type codes do not apply  
to physicians, other professionals and suppliers who bill these services to
the carrier or Part B MAC.  
  
Limitation of liability and refund requirements apply when denials are likely,
whether based on medical  
necessity or other coverage reasons. The provider/supplier must notify the
beneficiary in writing, prior to  
rendering the service, if the provider/supplier is aware that the test, item
or procedure may not be covered by  
Medicare. The limitation of liability and refund requirements do not apply
when the test, item or procedure is  
statutorily excluded, has no Medicare benefit category or is rendered for
screening purposes.  
  
For outpatient settings other than CORFs, references to "physicians"
throughout this policy include nonphysicians,  
such as nurse practitioners, clinical nurse specialists and physician
assistants. Such non-physician  
practitioners, with certain exceptions, may certify, order and establish the
plan of care as authorized by State  
law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social
Security Act; 42 CFR, Sections  
410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)