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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.
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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
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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.
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