Internal Medicine Coding Alert

Bone Mineral Density Studiesstudies used to evaluate diseases of bone and/or the responses of bone diseases to treatment. The studies assess bone mass or density associated with such diseases as osteoporosis, osteomalacia, and renal osteodystrophy.

Eligible HCPCS Codes

20220 Biopsy, bone, trocar, or needle; superficial (e.g., ilium, sternum, spinous process, ribs).

76070 Computerized tomography bone mineral density study, one or more sites.

Note: Code 76070 is only to be used on Medicare claims with dates of service prior to July 1, 1998. Following this date, HCPCS codes G0131 and G0132 replace this code.

76075 Dual energy x-ray absorptiometry (DEXA), bone density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine).

76076 DEXA, bone density study, one or more sites, appendicular skeleton (peripheral) (e.g., radius, wrist, heel).

76078 Radiographic absorptiometry (photodensitometry), one or more sites.

76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method.

Note: For claims with dates of service after July 1, 1999, HCPCS code G0133 replaces procedure code 76977.

Editors note: Code G0133 was added and deleted in the same year. This is Empires stated coverage policy only. Check with carriers for acceptance.

Effective for services on or after January 1, 1999:

78350 bone density (bone mineral content) study, one or more sites, single photon absorptiometry.

78351 dual photon absorptiometry, one or more sites.

78399 unlisted musculoskeletal procedure, diagnostic nuclear medicine.

G0130 single energy x-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton.

G0131 computerized tomography bone mineral density study, one or more sites; axial skeleton.

Effective for dates of service on or after July 1, 1998:

G0132 computerized tomography bone mineral density study, one or more sites; appendicular skeleton.

G0133 ultrasound bone mineral density study, one or more sites, appendicular skeleton.

Effective for dates of service prior to January 1, 1999:

G0062 peripheral skeleton bone mineral density studies (e.g., radius, wrist, heel). Note: This code is out of date.

Effective for dates of service on or before December 31, 1997:

G0063 central skeletal bone mineral density studies (e.g., spine, pelvis). Note: This code is out of date.

Indications and Limits of Coverage

Bone mass measurement is defined as a radiologic or radioisotopic procedure or other procedure:

- performed with a bone densitometer (other than dual photon absorptiometry) or a bone sonometer (i.e., ultrasound) device that has been approved or cleared for marketing by the Food and Drug Administration;

- performed on a qualified individual for the purpose of identifying bone mass or detecting bone loss or determining bone quality; and

- includes a physicians interpretation of the results of the procedure.

Qualified individual is defined as one who meets the medical indications for at least one of these four categories:

1. an individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, low bone mass (osteopenia), or vertebral fracture;

2. an individual receiving (or expecting to receive) gluccocorticoid (steroid) therapy equivalent to 7.5 mg of prednisone, or greater, per day, for more than three months;

3. an individual with primary hyperparathyroidism; or

4. an individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy.

Coverage criteria are as follows:

- tests are to be ordered by the individuals physician or qualified non-physician practitioner treating the beneficiary following an evaluation of the need for a measurement, including a determination as to the medically appropriate measurement to be used for the individual. For the purpose of the bone mass measurement benefit, qualified non-physician practitioners are physician assistants, nurse practitioners, clinical nurse specialists and certified nurse midwives;

- tests are 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;

- tests are furnished by a qualified supplier or provider of such services under at least a general level of supervision of a physician;

- tests are reasonable and necessary for diagnosing, treating, or monitoring a qualified individual as defined above.

Frequency Standard

Medicare may cover a bone mass measurement for a beneficiary once every two years. However, if medically necessary, Medicare may cover a bone mass measurement for a beneficiary more frequently than every two years. Examples of situations where more frequent bone mass measurements procedures may be medically necessary include monitoring beneficiaries on long-term gluccocorticoid therapy, and
allowing for a confirmatory baseline bone mass measurement to permit monitoring of beneficiaries in the future.

Eligible ICD-9 Codes

See list of eligible codes included with coverage instructions or those provided by your carrier.

Sources: Empire Medicare Services, New Jersey; and Health Care Financing Administration, Washington, DC.