LCD for Bone Density Measurement (L1343)

 

Contractor Information

Contractor Name 

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator) 

Contractor Number 

00390 

Contractor Type 

FI 

 

LCD Information

LCD ID Number 

L1343 

 

LCD Title 

Bone Density Measurement 

 

Contractor's Determination Number 

1343 

 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.  

 

CMS National Coverage Policy 

Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section excludes coverage of items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

Title IV of the Balanced Budget Act of 1997, Section 4106. This section includes language providing for Medicare coverage of bone mass measurements procedures, and coverage of FDA-approved bone mass measurement techniques and equipment for "qualified" individuals. These procedures are only covered when medically necessary.

CMS Pub 100-4, 13 Section 140-140.3
CMS pub 100-2, 15 Section 80.5

Program Memorandum HCFA AB-98-32.60
CMS Transmittal 1236, CR 5521, Medicare Claims Processing
CMS Transmittal 1416, CR 5847, Medicare Claims Processing 

 

Primary Geographic Jurisdiction 

New Jersey
Tennessee
 

 

Secondary Geographic Jurisdiction 

Alaska
Alabama
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California
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Connecticut
Florida
Georgia
Hawaii
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Ohio
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Pennsylvania
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South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
 

 

Oversight Region 

Region IV
 

 

 

Original Determination Effective Date 

For services performed on or after 01/01/1998  

 

Original Determination Ending Date 

 

 

Revision Effective Date 

For services performed on or after 03/07/2008  

 

Revision Ending Date 

 

 

Indications and Limitations of Coverage and/or Medical Necessity 

Bone mineral density (BMD) studies are performed to establish the diagnosis of osteoporosis. BMD by itself is a limited predictor, but when combined with other risk factors, BMD enhances the predictability of fracture.

A peripheral bone density study is covered for the beneficiary with a Colles’ fracture or other distal radius/ or ulnar fracture when the study is done because of suspicion that osteoporosis is a component of the cause of the fracture. If the diagnosis of osteoporosis were already established, this procedure would not be covered.

The term "qualified individual" means an individual who meets the medical indications for at least one of the five categories listed below:

 

  • A woman who has been determined by the physician or a qualified non-physician practitioner treating her to be estrogen-deficient and as clinical risk for osteoporosis, based on her medical history and other findings
  • An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral fracture
  • An individual receiving (or expecting to receive glucocorticoid (steroid) therapy equivalent to 5 mg of prednisone, or greater, per day, for more than three (3) months
  • An individual with primary hyperparathyroidism
  • An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy


Medicare will cover bone mass measurements when they are:

 

  • Ordered by the individual's physician or qualified non-physician practitioner treating the beneficiary following an evaluation to the need for a measurement, including a determination as to be medically appropriate measurement to be used
  • Furnished by a qualified supplier or provider of such services under at lease the general level of supervision of a physician as defined in section 1861 (r) of the social Security Act
  • Reasonable and necessary for diagnosing, treating, or monitoring a "qualified individual"
  • Performed with a bone densitometer or a bone sonometer device approved or cleared for marketing by the FDA for bone mass measurement purposes, with the exception of DPA devices


Coverage for Colles' or other fractures would only be covered once. The peripheral study in these situations is covered when done by the following instruments: dual energy x-ray absorptiometry, radiographic absorptiometry, or computed tomography.

A central bone density study is covered for the following indications, when done with a stationary dual energy x-ray absorptiometry or quantitative computed tomography instrument:

 

  • A beneficiary with a recent fracture of the spine, long bone, hip or pelvis and when the fracture is suspected to be associated with osteoporosis.
  • A beneficiary with known osteoporosis on therapy with drugs known to decrease or stop the loss of BMD, the test is done to determine response to therapy; (for this indication the test is covered once, 12-18 months after the initiation of therapy only if the result is being used to determine if the treatment needs to be changed.
  • A beneficiary on long term corticosteroid therapy (greater than 3 months, on the equivalent dose of 30 mg cortisone or greater per day). For this indication the test is only covered once and only if the test is being used to determine if the beneficiary is to be treated with drugs to decrease or stop the loss of BMD.
  • A beneficiary on long-term use (greater than 1 month) of heparin therapy. For this indication the test is covered only once and only when the result is being used to determine if the beneficiary is to be treated with drugs to decrease or stop the loss of BMD.
  • A beneficiary on long-term (greater than 3 months) phenytoin therapy. For this indication the test is covered no more frequently than every 12-18 months and only when the result is being used to determine if the phenytoin is to be discontinued and/or drugs added to increase bone density.
  • A beneficiary with known hyperparathyroidism when the test results are being used to determine if the beneficiary requires a parathyroidectomy.
  • A beneficiary on excessive doses of thyroid replacement (for this indication the test is covered only if the beneficiary has a subnormal TSH level while on thyroid replacement). Densitometry measurement for this purpose would be allowed only once.
  • For beneficiary with known osteoporosis, repeat bone density study of the bone involved, done 12-18 months after initiation of therapy with drugs known to decrease or stop the loss of BMD, would be covered if done to determine the effect of therapy. If results indicate treatment is ineffective, after the change in treatment, a repeat study would be allowed, again at 12-18 months after initiation of the new treatment.


Medicare reimbursement for Bone Densitometry, whether done by DEXA, RA, Ultrasound, Sexa or QCT, is allowed only once no matter how many sites are studied. (E.g., if the spine and hip are studied, 77078 should be billed only once)

A physician or other qualified practitioner may determine by history and examination that a woman is estrogen deficient and at clinical risk for osteoporosis. In the absence of the complications not above, Medicare may cover a bone density study once every 2 years (i.e. at least 23 months must pass since prior study) A more frequent examination must be supported by unusual and compelling medical necessity as documented in the Medical Records.

 

 

Coverage Topic 

Diagnostic Tests and X-Rays
 

 

Coding Information

Bill Type Codes: 

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12x

Hospital-inpatient or home health visits (Part B only)

13x

Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)

 

 

Revenue Codes: 

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

032X

Radiology diagnostic-general classification

 

 

CPT/HCPCS Codes 

Dual photon absorptiometry is non-covered by Medicare.
Single photon absorptiometry is non-covered by Medicare.

76977

ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETATION, PERIPHERAL SITE(S), ANY METHOD

77078

COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE)

77079

COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES; APPENDICULAR SKELETON (PERIPHERAL) (EG, RADIUS, WRIST, HEEL)

77080

DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE)

77081

DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; APPENDICULAR SKELETON (PERIPHERAL) (EG, RADIUS, WRIST, HEEL)

77083

RADIOGRAPHIC ABSORPTIOMETRY (EG, PHOTODENSITOMETRY, RADIOGRAMMETRY), 1 OR MORE SITES

G0130

SINGLE ENERGY X-RAY ABSORPTIOMETRY (SEXA) BONE DENSITY STUDY, ONE OR MORE SITES; APPENDICULAR SKELETON (PERIPHERAL) (EG, RADIUS, WRIST, HEEL)

 

 

ICD-9 Codes that Support Medical Necessity 

CPT codes 77078, 77079, 77081, 77083, 76977, or G0130 will be denied if the claim contains ICD-9-CM diagnosis codes 733.00, 733.01, 733.02, 733.03, 733.09, 733.90 or 255.0 and does not contain an additional ICD-9-CM code from ICD-9 Group 1 below.

244.0 - 244.9

POSTSURGICAL HYPOTHYROIDISM - UNSPECIFIED ACQUIRED HYPOTHYROIDISM

252.00

HYPERPARATHYROIDISM, UNSPECIFIED

252.01

PRIMARY HYPERPARATHYROIDISM

252.02

SECONDARY HYPERPARATHYROIDISM, NON-RENAL

252.08

OTHER HYPERPARATHYROIDISM

255.0

CUSHING'S SYNDROME

256.2

POSTABLATIVE OVARIAN FAILURE

256.31 - 256.39

PREMATURE MENOPAUSE - OTHER OVARIAN FAILURE

259.3

ECTOPIC HORMONE SECRETION NOT ELSEWHERE CLASSIFIED

627.2

SYMPTOMATIC MENOPAUSAL OR FEMALE CLIMACTERIC STATES

627.4

SYMPTOMATIC STATES ASSOCIATED WITH ARTIFICIAL MENOPAUSE

627.9

UNSPECIFIED MENOPAUSAL AND POSTMENOPAUSAL DISORDER

719.45

PAIN IN JOINT INVOLVING PELVIC REGION AND THIGH

724.1

PAIN IN THORACIC SPINE

724.2

LUMBAGO

731.0

OSTEITIS DEFORMANS WITHOUT BONE TUMOR

731.2

HYPERTROPHIC PULMONARY OSTEOARTHROPATHY

733.00 - 733.09

OSTEOPOROSIS UNSPECIFIED - OTHER OSTEOPOROSIS

733.13

PATHOLOGICAL FRACTURE OF VERTEBRAE

733.7

ALGONEURODYSTROPHY

733.90

DISORDER OF BONE AND CARTILAGE UNSPECIFIED

756.50

CONGENITAL OSTEODYSTROPHY UNSPECIFIED

756.59

OTHER CONGENITAL OSTEODYSTROPHIES

758.6

GONADAL DYSGENESIS

805.00 - 805.9

CLOSED FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL - OPEN FRACTURE OF UNSPECIFIED PART OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY

806.00 - 806.09

CLOSED FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

806.10 - 806.19

OPEN FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

806.20 - 806.29

CLOSED FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

806.30 - 806.39

OPEN FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

806.4

CLOSED FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY

806.5

OPEN FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY

806.60 - 806.69

CLOSED FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY

806.70 - 806.79

OPEN FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY

806.8

CLOSED FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY

806.9

OPEN FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY

807.01

CLOSED FRACTURE OF ONE RIB

807.02

CLOSED FRACTURE OF TWO RIBS

808.0 - 808.9

CLOSED FRACTURE OF ACETABULUM - UNSPECIFIED OPEN FRACTURE OF PELVIS

813.40 - 813.54

CLOSED FRACTURE OF LOWER END OF FOREARM UNSPECIFIED - FRACTURE OF LOWER END OF RADIUS WITH ULNA OPEN

820.00 - 820.09

FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK OF FEMUR CLOSED - OTHER TRANSCERVICAL FRACTURE OF FEMUR CLOSED

E932.0

ADRENAL CORTICAL STEROIDS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

V45.77

ACQUIRED ABSENCE OF ORGAN GENITAL ORGANS

V49.81

ASYMPTOMATIC POSTMENOPAUSAL STATUS (AGE-RELATED) (NATURAL)

V58.61

LONG-TERM (CURRENT) USE OF ANTICOAGULANTS

V58.63

LONG-TERM (CURRENT) USE OF ANTIPLATELETS/ANTITHROMBOTICS

V58.65

LONG-TERM (CURRENT) USE OF STEROIDS

V58.69

LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS

V67.51

FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED

V67.59

OTHER FOLLOW-UP EXAMINATION

 

 

Diagnoses that Support Medical Necessity 

 

 

ICD-9 Codes that DO NOT Support Medical Necessity 

 

 

 

 

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation 

 

 

Diagnoses that DO NOT Support Medical Necessity 

 

 

General Information

Documentation Requirements 

Documentation supporting medical necessity of this item, such as ICD-9 codes, diagnosis and frequency must be submitted with each claim. Claims without such evidence will be denied. 

 

Appendices 

 

 

Utilization Guidelines 

 

 

Sources of Information and Basis for Decision 

Carrier Policy 

 

Advisory Committee Meeting Notes 

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from appropriate specialties as well as provider (facility) representatives. 

 

Start Date of Comment Period 

10/16/1997 

 

End Date of Comment Period 

 

 

Start Date of Notice Period 

12/01/1997 

 

Revision History Number 

R1343a 

 

Revision History Explanation 

10/01/1004 Annual ICD-9 Code Update: Replaced 252.0 with 252.00, 252.01, 252.02, 252.08. All revisions found in field ICD-9 Codes that Support Medical Necessity.

07/29/2004 Crosswalked to Online Manual

10/01/2003 Annual ICD-9 Code Update: Added V58.61, V58.63, and V58.65 in ICD-9 Codes that Support Medical Necessity field.

07/17/2003 Replaced CPT/HCPCS codes G0131 and G0132 with 76070 and 76071. Also added CPT code 76977 and deleted paragraph found in CPT/HCPCS Codes field stating: "Computerized tomography, bone density study, one or more sites moved to non-covered status by HCFA. See Program Memorandum Intermediaries/Carriers AB-98-32." [both a result of clerical oversight].

01/09/2003 Added 12x to Type of Bill Code

07/24/2002 Formatted

12/07/2001 Updated ICD-9 [2002 Code Book]

02/23/2001 Updated CPT and ICD-9 codes with 2001 code books

08/29/2000 Revision performed to expand documented coverage in compliance with HCFA National Policy.

11/07/2004 - The description for CPT/HCPCS code 76075 was changed in group 1
11/07/2004 - The description for CPT/HCPCS code 76076 was changed in group 1

This LCD was converted from an LMRP on 12/7/2005

7/2/2006 - The description for Bill code 14 was changed

11/18/2006 - CPT/HCPCS code 76070 was deleted from group 1
11/18/2006 - CPT/HCPCS code 76071 was deleted from group 1
11/18/2006 - CPT/HCPCS code 76075 was deleted from group 1
11/18/2006 - CPT/HCPCS code 76076 was deleted from group 1
11/18/2006 - CPT/HCPCS code 76078 was deleted from group 1

1/11/2007 - CPT/HCPCS code 77078 was added to group 1
1/11/2007 - CPT/HCPCS code 77079 was added to group 1
1/11/2007 - CPT/HCPCS code 77080 was added to group 1, and Indications and Limitations of coverage, paragraph 8
1/11/2007 - CPT/HCPCS code 77081 was added to group 1
1/11/2007 - CPT/HCPCS code 77083 was added to group 1

3/07/2008 - Narrative changes from CR 5521
3/07/2008 - CPT/HCPCS code 78350 removed from group 1, CR 5521
3/07/2008 - Diagnosis codes V45.77 and V49.81 added to group 1
3/07/2008 - CR 5847 narrative changes made: CPT codes 77078, 77079, 77081, 77083, 76977, or G0130 will be denied if the claim contains ICD-9-CM diagnosis codes 733.00, 733.01, 733.02, 733.03, 733.09, 733.90 or 255.0 and does not contain an additional ICD-9-CM code from ICD-9 Group 1. 

 

Reason for Change 

CMS Requirement
HCPCS Addition/Deletion
ICD9 Addition/Deletion
Narrative Change
 

Last Reviewed On Date 

03/07/2008 

 

Related Documents 

Article(s)
A37895 - Bone Density Measurement

 

LCD Attachments 

FAQ (1,734 bytes)

 

Other Versions 

Updated on 01/11/2007 with effective dates 12/08/2005 - 03/06/2008

Updated on 09/01/2006 with effective dates 12/08/2005 - N/A

Updated on 07/02/2006 with effective dates 12/08/2005 - N/A

Updated on 12/07/2005 with effective dates 12/08/2005 - N/A

Updated on 12/07/2005 with effective dates 11/07/2004 - 12/07/2005

Updated on 11/07/2004 with effective dates 10/01/2004 - 11/06/2004

Updated on 09/22/2004 with effective dates 10/01/2004 - N/A

Updated on 09/15/2004 with effective dates 10/01/2003 - 09/30/2004

Updated on 09/08/2004 with effective dates 10/01/2003 - N/A

Updated on 07/29/2004 with effective dates 10/01/2003 - N/A

Updated on 10/09/2003 with effective dates 10/01/2003 - N/A

Updated on 10/03/2003 with effective dates 10/05/2003 - 09/30/2003

Updated on 10/02/2003 with effective dates 10/01/2003 - 10/04/2003

Updated on 09/22/2003 with effective dates 10/01/2003 - N/A

Updated on 09/18/2003 with effective dates 10/01/2003 - N/A

Updated on 09/17/2003 with effective dates 10/01/2003 - N/A

Updated on 09/17/2003 with effective dates 10/01/2003 - N/A

Updated on 07/16/2003 with effective dates 07/17/2003 - 09/30/2003

Updated on 03/11/2003 with effective dates 01/09/2003 - 07/16/2003

Updated on 03/11/2003 with effective dates 01/09/2003 - N/A

Updated on 02/15/2003 with effective dates 01/09/2003 - N/A

Updated on 01/08/2003 with effective dates 01/09/2003 - N/A

Updated on 10/04/2002 with effective dates 07/24/2002 - 01/08/2003