cpt code 78350, 78351, 77080 and 77086

May 6, 2021 | Medical billing basics

CPT code and Description 

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

77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)

Billing 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.

The following two studies are not covered:

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

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 single or 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:

*  A woman who has been determined by the physician or qualified non-physician practitioner treating her to be estrogendeficient and at clinical risk for osteoporosis, based on her medical history and other findings

Note: Since not every woman who has been prescribed estrogen replacement therapy (ERT) may be receiving an “adequate” dose of the therapy, the fact that a woman is receiving ERT should not preclude her treating physician or other qualified treating non-physician practitioner from ordering a bone mass measurement for her. If a bone mass measurement is ordered for a woman following a careful evaluation of her medical need, however, it is expected that the ordering/treating physician (or other qualified treating non-physician practitioner) will document in her medical record why he or she believes that the woman is estrogen-deficient and at clinical risk for osteoporosis.

* 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 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.

This service must be performed using dual energy x-ray absorptiometry system (axial skeleton).

It is furnished by a qualified supplier or provider of such services, under at least the general level of supervision of a physician as defined in 42 CFR 410.32(b)

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 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 A confirmatory baseline BMM is not covered if the initial BMM was performed by a dual-energy x-ray absorptiometry system (axial skeleton).

It is not medically necessary to have both peripheral and axial BMM tests performed on the same day.

Documentation Requirements

If the provider of the service is other than the ordering/referring physician/nonphysician practitioner, that provider must maintain a copy of test results and interpretation, along with copies of the ordering/referring physician/nonphysician practitioner’s order for the studies. The clinical indication/medical necessity for the study must be indicated in the order for the test.

Applicable Codes

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.

CPT Code Description

77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)

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 of sites 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 a DXA 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 been performed within the defined coverage period, as stated above, unless as confirmatory testing for future monitoring. Beneficiaries must authorize providers to obtain prior test results. If unsuccessful efforts to obtain prior test results from another provider are documented, new tests may be considered for reimbursement.
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 when performed by a portable x-ray supplier. Transportation charges for BMM testing will be denied. 
8. BONE mass measurement tests provided without an accompanying interpretation and report, as part of the test, will be denied as not medically necessary.
9. BONE mass measurement tests will be denied as not medically necessary if performed by a non-physician practitioner.
10. CPT code 77082 is considered by Medicare to represent vertebral fracture assessment only. Because code 77082 does not represent a BONE density study, it should NOT be billed for screening. This code may 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 test will be used in the management of the patient.
Overview
This Coverage Policy addresses bone mineral density measurement using various testing methods and vertebral fracture assessment by using dual-energy x-ray absorptiometry (DXA).
Coverage Policy
In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.
SCREENING
Coverage for preventive care including bone mineral density measurement for screening for osteoporosis varies across plans. Refer to the customer’s benefit plan document for coverage details. Any of the following bone mineral density measurement testing methods is considered medically necessary as screening for osteoporosis:
• peripheral ultrasound (CPT® 76977)
• central dual x-ray absorptiometry (DXA) (CPT® 77080)
• peripheral DXA (CPT® 77081)
• peripheral single energy x-ray absorptiometry (HCPCS code G0130) for ANY of the following indications:
• woman age =65 years
• postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool (e.g., FRAX*)
• man age >50 years with at least one factor related to an increased risk of osteoporosis (i.e., age > 70, low body weight, weight loss >10%, physical inactivity, corticosteroid use, androgen deprivation therapy, hypogonadism and previous fragility fracture) Computed tomography (CT) (CPT® 77078) for bone mineral density measurement testing is considered medically necessary as screening for osteoporosis when DXA scanner is unavailable or known to be inaccurate for ANY of the following indications:
• woman age =65 years
• postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool (e.g., FRAX*)
• man age >50 years with at least one factor related to an increased risk of osteoporosis (i.e., age > 70, low body weight, weight loss >10%, physical inactivity, corticosteroid use, androgen deprivation therapy, hypogonadism and previous fragility fracture)
* Fracture Risk Assessment (FRAX®) tool, developed by the World Health Organization (Sheffield, United Kingdom) Repeat bone density measurement is considered medically necessary every two years. Bone mineral density measurement for screening for osteoporosis for any other population is considered experimental, investigational or unproven.
NON-SCREENING/MONITORING
Any of the following bone mineral density measurement testing methods is considered medically necessary:
• peripheral ultrasound (CPT® 76977)
• central dual x-ray absorptiometry (DXA) (CPT® 77080)
• peripheral DXA (CPT® 77081)
• peripheral single energy x-ray absorptiometry (HCPCS code G0130) for ANY of the following indications:
• prior to and during pharmacologic treatment for osteoporosis*
• child or adolescent with a disease process known to adversely affect the skeleton
• known osteoporotic fracture
• individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture
*central DXA assessment of the hip or lumbar spine is preferred

VERTEBRAL FRACTURE ASSESSMENT (77086)
Paramount covers vertebral fracture assessment by dual-energy x-ray absorptiometry (DEXA) 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 test will be used in the management of the patient. Code 77086 does not represent a bone density study and it therefore should NOT be billed for screening.
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