Article - Billing and Coding: Bone Mass Measurement (A57132)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessaryfor the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to processthe claim.Section 1861(r) provides the definition of a physician.Section 1861(s)(2)(V)(15) includes bone mass measurement as a physician service.Section 1861(rr) provides the definition of bone mass measurement.Code of Federal Regulations:Title IV of the Balanced Budget Act of 1997, Section 4106 includes language providing for Medicare coverageof bone mass measurement procedures, and coverage of FDA-approved bone mass measurement techniquesand equipment for "qualified" individuals. These procedures are only covered when medically necessary.CMS Publications:CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15:80.5 Bone Mass Measurements (BMMs)CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations, Chapter 1:150.3 Bone (Mineral) Density Studies (Effective January 1, 2007)CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13:140 Bone Mass Measurements (BMMs).Article TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policyL36460-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 GuidelinesAn 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 RequirementsThe patients 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 historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)+Earlier technologies, such assingle and dual photon absorptiometry( CPT code 78350 or 78351), are nolonger 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 ofsites 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 aDXA 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 beenperformed within the defined coverage period, as stated above, unless as confirmatory testing for futuremonitoring. Beneficiaries must authorize providers to obtain prior test results. If unsuccessful efforts toobtain prior test results from another provider are documented, new tests may be considered forreimbursement.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 whenperformed 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 ofthe 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. Becausecode 77082 does not represent a bone density study, it should NOT be billed for screening. This codemay 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 testwill 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 theprimary 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 applyto 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 medicalnecessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior torendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered byMedicare. The limitation of liability and refund requirements do not apply when the test, item or procedure isstatutorily 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-physicianpractitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by Statelaw. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)