Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) will implement Change Request (CR) 9252 on January 4, 2016, effective October 1, 2015. (See related MLN Matters® article MM9252.) This CR establishes the list of covered conditions and corresponding ICD-10-CM diagnosis codes approved for Bone Mass Measurement studies according to the requirements set forth in National Coverage Determination (NCD) 150.3. CR9252 and accompanying spreadsheet inadvertently omitted the condition of osteopenia and the ICD- 10-CM codes that describe it which are classified to subcategory M85.8- Other specified disorders of bone density and structure. The codes and conditions identified within this subcategory are considered covered indications for bone mass measurement under NCD 150.3 and providers should report these appropriately according to medical documentation.
Additional guidance and education as to the updated complete list of covered indications will be forthcoming as CMS continues to review this issue and the systems updates required. Under ICD-9-CM, the term “Osteopenia” was indexed to ICD-9-CM diagnosis code 733.90 (Disorder of bone and cartilage). This code was listed as a covered condition under the Business requirement 5521.1.1 for CR 5521/NCD 150.3, dated May 11, 2007, when reported with CPT code 77080. (See related MLN Matters article MM552
Under ICD-10-CM, the term “Osteopenia” is indexed to ICD-10-CM subcategory M85.8- Other specified disorders of bone density and structure, within the ICD-10-CM Alphabetic Index. The codes within this subcategory were inadvertently omitted from the CMS spreadsheet that accompanied CR 9252 containing the list of covered conditions and corresponding diagnosis codes. These are considered covered for NCD 150.3 indications.
Below is the list of ICD-10-CM diagnosis codes within subcategory M85.8- that providers may report as covered indications in addition to the current list provided in CR 9252 and its accompanying CMS spreadsheet.
** M85.811 Other specified disorders of bone density and structure, right shoulder
** M85.812 Other specified disorders of bone density and structure, left shoulder
** M85.821 Other specified disorders of bone density and structure, right upper arm
** M85.822 Other specified disorders of bone density and structure, left upper arm
** M85.831 Other specified disorders of bone density and structure, right forearm
** M85.832 Other specified disorders of bone density and structure, left forearm
** M85.841 Other specified disorders of bone density and structure, right hand
** M85.842 Other specified disorders of bone density and structure, left hand
** M85.851 Other specified disorders of bone density and structure, right thigh
** M85.852 Other specified disorders of bone density and structure, left thigh
** M85.861 Other specified disorders of bone density and structure, right lower leg
** M85.862 Other specified disorders of bone density and structure, left lower leg
** M85.871 Other specified disorders of bone density and structure, right ankle and foot
** M85.872 Other specified disorders of bone density and structure, left ankle and foot
** M85.88 Other specified disorders of bone density and structure, other site
** M85.89 Other specified disorders of bone density and structure, multiple sites
Question 1 When will the LCD be updated to either remove Osteopenia as an indication or include the ICD-10 diagnosis codes for Osteopenia?
Answer
• The ICD-10 codes that crosswalk with Osteopenia are under subcategory M85.8 and do not refer to Osteopenia. They are a group of very nonspecific disorders of bone density which do NOT justify or qualify for Vitamin D testing. • The specificity of the ICD-10 testing has refined what disorders qualify for coverage of Oncology Cytogenetics and have allowed us to cull out diagnoses that were previously covered but should not have been. We feel at present the appropriate diagnoses are covered and do not plan on developing a LCD that will expand on the covered ICD-10 codes that CMS has established in NCD 190.3
Guidelines
Each claim must be submitted with the diagnosis codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. The patient’s medical record must document that the patient meets one of the requirements of a “qualified individual” as described in the guidelines below. Documentation must be available upon request. It is the responsibility of the provider to code to the highest level specified. The correct use of a diagnosis code listed, does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified.
BMM tests provided without an accompanying interpretation and report, as part of the test, will be denied as not medically necessary.
CPT 77085 should NOT be billed for screening and is not part of the Preventive Benefit. Member cost share will apply when medically necessary criteria are met.
The following two studies are not covered by Medicare:
* 78350: Bone density (bone mineral content) study, 1 or more sites; single photon absorptiometry
* 78351: Bone density (bone mineral content) study, 1 or more sites; dual photon absorptiometry
ICD-10-CM code Z90.721 or Z90.722 should be reported for women s/p oophorectomy.
ICD-10-CM code Z79.51 or Z79.52 should be reported for an individual on glucocorticoid therapy.
ICD-10-CM code Z79.83 should be reported for DXA testing while taking medicines for osteoporosis/osteopenia.
ICD-10-CM Z09 should be reported for an individual who has COMPLETED drug therapy for osteoporosis and is being monitored for response to the therapy.
Medicare covers a bone mass measurement for a beneficiary once every two years (if at least 23 months have passed since the month the last bone measurement was performed). The criteria for bone mass measurement every two years are listed below:
It is performed with a bone densitometer, other than dual photon absorptiometry (DPA) or a bone sonometer (e.g., ultrasound) device that has been approved or cleared for marketing by the Food and Drug Administration (FDA).
It is performed on a qualified individual for the purpose of identifying bone mass, detecting bone loss or determining bone quality. The term “qualified individual” means an individual who meets the medical indications for at least one of the criteria listed below:
o A woman who has been determined by the physician or qualified non-physician treating her to be estrogendeficient and at clinical risk for osteoporosis, based on her medical history and other indicators
o An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral fracture
o An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to 5 mg of Prednisone, or greater, per day for more than 3 months
o An individual with primary hyperparathyroidism
o An individual being monitored to assess the response to or efficacy of an FDA approved osteoporosis drug therapy. This service must be performed using dual energy x-ray absorptiometry system (axial skeleton) – CPT code 77080 and 77085
* If it is furnished by a qualified supplier or provider of such services, under at least general level of supervision of a physician.
* If the test is ordered by the individual’s physician or qualified non-physician practitioner, who is treating the beneficiary following an evaluation of the need for the measurement, including a determination as to the medically appropriate measurement to be used for the individual, and who uses the results in the management of the
patient.
* The test is reasonable and necessary for diagnosing, treating or monitoring of a “qualified” individual as defined above.
For conditions specified below, Medicare will cover a bone mass measurement for a qualified beneficiary more frequently than every two years, if medically necessary. To be considered, at least eleven months must have elapsed since the previous bone mass measurement test. Such conditions are:
* Monitoring beneficiaries on long-term glucocorticoid (steroid) therapy, equal to 5 mg of Prednisone or greater, per day for more than three months.
* Follow up bone mineral density testing to assess FDA-approved osteoporosis drug therapy until a response to such therapy has been documented over time.
* Confirming baseline BMMs to permit monitoring of beneficiaries in the future.
Medicare will cover a confirmatory baseline bone mass measurement when it is performed with a dual energy x-ray absorptionmetry system (axial skeletal) to permit monitoring of beneficiaries in the future, if the initial test was performed with a technique that is different from the proposed monitoring method (for example, if the initial test was bone sonometry and the patient will be monitored with bone densitometry, a second test utilizing densitometry will be paid). If the initial bone mass measurement was performed by a dual-energy x-ray absorptionmetry system (axial skeletal), a confirmatory BMM is not covered.
