(Medicare Claims Processing Manual)

76070 76071 76075 76076 76078 76977 78350 G0130  Effective for dates of services on and after January 1, 2007, the following changes apply to BMM:   New 2007 CPT bone mass procedure codes have been assigned for BMM.  The following codes will replace current codes, however the CPT descriptors for the services remain the same:  77078 replaces 76070  77079 replaces 76071  77080 replaces 76075  77081 replaces 76076  77083 replaces 76078  Effective for dates of service on and after January 1, 2015, contractors shall pay for bone mass procedure code 77085 ( Dual -energy X -ray absorptiometry (DXA), bone density study, 1 or more sites, axial skeleton, (e.g., hips, pelvis, spine), including vertebral fracture assessment.)   Certain BMM tests are covered when used to screen patients for osteoporosis subject to the frequency standards described in chapter 15, section 80.5.5 of the Medicare Benefit Policy Manual. Contractors will pay claims for screening tests when coded as follows:   Contains CPT procedure code 77078, 77079, 77080, 77081, 77083, 76977 or  G0130, and  Contains a valid diagnosis code indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.  Contractors are to maintain local lists of valid codes for the benefits screening categories.  Contractors will deny claims for screening tests when coded as follows:  Contains CPT procedure code 77078, 77079, 77081, 77083, 76977 or G0130, but  Does not contain a valid diagnosis code from the local lists of valid diagnosis codes maintained by the contractor for the benefits screening categories 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 described in chapter 15, section 80.5.5 of the Medicare Benefit Policy Manual . Contractors will pay  claims for monitoring tests when coded as follows:  Contains CPT procedure code 77080 or 77085, and Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0 as the ICD -9-CM diagnosis code or M81.0, M81.8, M81.6 or M94.9 as the ICD -10-CM diagnosis code. Contractors will deny claims for monitoring tests when coded as follows:  Contains CPT procedure code 77078, 77079, 77081, 77083, 76977 or G0130, and  Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0 as the ICD -9-CM diagnosis code, but  Does not contain a valid ICD -9-CM diagnosis code from the local lists of valid ICD -9-CM diagnosis codes maintained by the contractor for the benefits screening categories indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.   Does not contain a valid ICD -10-CM diagnosis code from the local lists of valid ICD -10-CM diagnosis codes maintained by the contractor for the benefits screening categories indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.   Single photon absorptiometry tests are not covered.  Contractors will deny CPT procedure code 78350.  The A/B MACs (A) are billed using the ASC X12 837 institutional claim format or hardcopy Form CMS -1450.  The appropriate bill types are: 12X, 13X, 22X, 23X, 34X, 71X (Provider -based and independent), 72X, 77X (Provider -based and freestanding), 83X, and 85X.  Effective April 1, 2006, type of bill 14X is for non- patient laboratory specimens and is no longer applicable for bone mass measurements.  Information regarding the claim form locators that correspond to the HCPCS/CPT code or Type of Bill ar e found in chapter 25.  Providers must report HCPCS codes for bone mass measurements under revenue code 320 with number of units and line item dates of service per revenue code line for each bone mass measurement reported.   A/B MACs (B) are billed for bone mass measurement procedures using the ASC X12 837 professional claim format or hardcopy Form CMS -1500.  140.2 - Denial Messages for Noncovered Bone Mass Measurements  (Rev. 3650, Issued: 11- 10-16, Effective: 02 -10-17, Implementation: 02- 10-17)  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under the conditions described in 140.1.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: PR (if claim is received with a GA modifier) otherwise CO  CARC: 50  RARC: Alert M38 (if ABN was issued) or M27 (if ABN was not issued)  MSN: 16.10 and 36.1 (if ABN was issued) or 36.2 (if ABN was not issued)   NOTE:   A/B MACs (A) are not to include MSN 16.10.  140.4  Advance Beneficiary Notices (ABNs)  (Rev. 1236, Issued: 05- 11-07, Effective: 01 -01-07, Implementation: 07- 02-07)  For the denial situations listed in Section 140.1, physicians, practitioners  and hospitals are liable for payment unless they issue an appropriate ABN.  Contractors will utilize the appropriate messages, see sections 140.2 and 140.3.  150 - Place of Service (POS) Instructions for the Professional Component (PC or Interpretation) and the Technical Component (TC) of Diagnostic Tests (Rev. 3315, Issued: 08- 06-15, Effective: 01 -01-16, Implementation: 01- 04-16)  Many of the diagnostic services, including radiology services, provided by physicians/practitioners contain both a technical component (TC) and a professional component (PC).  Often, the PC and TC of diagnostic services are furnished in different settings.   As a general policy, the POS code assigned by the physician/practitioner for the PC of a diagnostic service shall be the setting in which the beneficiary received the TC service.   A.  Interpretation Provided Telephonically by Wireless Remote   Teleradiology services (radiology services that do not require a face -to-face encounter with the patient furnished through the use of a telecommunications system) are discussed in Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15, section 30.  The interpretation of an x -ray, electrocardiogram, electroencephalogram and tissue samples are listed as examples of these services.   In cases where the face -to-face requirement is obviated such as those when a physician/practitioner provides the PC/interpretation of a diagnostic test, from a distant site, the POS code assigned by the physician /practitioner shall be the setting in which the beneficiary received the TC service.  The POS code for a teleradiology interpretation is generally the place where the beneficiary received the TC, or face- to-face encounter.  The POS code representing the setting where the beneficiary received the TC  is entered in the ASC X12 837 professional claim format or in item 24B on the paper claim Form CMS 1500.  In cases where it is unclear which POS code applies, the Medicare contractor can provide guidance.   For example:  A beneficiary receives an MRI on an outpatient hospital campus near his/her home.  The outpatient hospital submits a claim that would correspond to the TC portion of the MRI.  The physician furnishes the PC portion of the beneficiarys MRI from his/her office location -  POS code 22 (On Campus -Outpatient Hospital) shall be used on the physicians claim to indicate that the beneficiary received the face -to-face portion of the MRI, the TC, on the campus of an outpatient hospital.    B.  Interpretation Provided Outside of the United States   Generally, Medicare will not pay for health care or supplies that are performed outside the United States (U.S.).  The term outside the U.S. means anywhere other than the 50 states of the U.S., the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.  See Pub. 100- 02, chapter 16, section 60, for exceptions to the outside the U.S. exclusions.   C.  Interpretation Provided Under Arrangement -  To A Hospital   Separate TC and PC   If a diagnostic test which has a separate TC and PC is provided under arrangement to a hospital, the physician who reads the test can bill and be paid for the professional component.  Both the technical and professional components of the test are also subject to the physician self -referral prohibition.  The appropriate POS code for the interpretation (or PC) is the setting where the beneficiary received the TC service.  If the interpretation is performed in the physicians office and the patient received the TC service in the provider -based outpatient hos pital setting, the physician assigns POS code 22, for On Campus -Outpatient Hospital, or POS 19, for Off Campus -Outpatient Hospital, on the claim for the interpretation or PC.   Global Service   When a physician performs a diagnostic test under arrangement to a hospital and the test and the interpretation are not separately billable, the interpretation cannot be billed by the physician.  In this scenario, the hospital is the only entity that can bill for the diagnostic test which encompasses the interpretation.  There is no POS code for the interpretation since a physician claim is not generated.   D.  Global Billing   Billing globally for services that are split into PC and TC components is only possible when the TC and the physician who provides the PC of the diagnostic service are furnished by the same physician or supplier entity and the PC and TC components are furnished within the same Medicare physician fee schedule payment locality.  Merely applying the same POS code to the PC as that of the TC (as described in A above) does not permit global billing for any diagnostic procedure.   E.  Determination of Payment Locality  Under the Medicare physician fee schedule (MPFS), payment amounts are based on the relative resources required to provide services and vary among payment localities as resource costs vary geographically as measured by the geographic practice cost indices (GPCIs).   The payment locality is determined based on the location where a specific service code was furnished.  For purposes of determining the appropriate payment locality, CMS requires that the address, including the ZIP code for each service code be included on the claim form in order to determine the appropriate payment locality.  The location in which the service code was furnished is entered on the ASC X12 837 professional claim format or in Item 32 on the paper claim Form CMS 1500.  Global Service Code   If the global diagnostic service code is billed, the biller (either the entity that took the test, physician who interpreted the test, or separate billing agent) must report the address and ZIP code of where the test was furnished on the bill for the globa l diagnostic service code.  In other words, when the global diagnostic service code is billed, for example, chest x -ray as described by HCPCS code 71010 (no modifier TC and no modifier - 26), the locality is determined by the ZIP code applicable to the testing facility, i.e. where the TC of the chest x -ray was furnished.  The testing facility (or its billing agent) enters the address and ZIP code of the setting/location where the test took place.  This practice location is entered using the ASC X12 837 profe ssional claim format or in Item 32 on the paper claim Form CMS 1500.  As explained in D above, in order to bill for a global diagnostic service code, the same physician or supplier entity must furnish both the TC and the PC of the diagnostic service and the TC and PC must be furnished within the same MPFS payment locality.   Separate Billing of Professional Interpretation   If the same physician or other supplier entity does not furnish both the TC and PC of the diagnostic service, or if the same physician or other supplier entity furnishes both the TC and PC but the professional interpretation was furnished in a different pa yment locality from where the TC was furnished, the professional interpretation of a diagnostic test must be separately billed with modifier - 26 by the interpreting physician.