Separate screening from monitoring for spot-on coding. Bone mass measurement (BMM) has been in the spotlight lately after Medicare once again changed payment calculations for DXA bone density studies. That makes now a great time to review coverage requirements for these common tests. (Hint: Check out section 5 for more about the payment changes.) 1. Verify Order Is From a Qualified Provider For Medicare to cover BMM, the test must be ordered by a physician or qualified nonphysician provider (NPP), according to Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 80.5.4 (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf). NPPs qualified to order BMM include: The ordering physician or NPP must be "treating" the patient, evaluate the need for BMM, and determine the appropriate BMM for the patient. "Treating" means either consulting or treating the patient for a specific problem and using the results to further manage the patient, according to the MBPM. 2. Factor in Frequency Requirements Medicare offers a general frequency limitation for BMM, but it does allow exceptions for medically necessary scans. Screening: Example: Practical solution: "For practices that don't have that type of software feature or haven't shifted to an EMR, some may consider using two 12-month accordion file folders or a recipe box with dividers for each of the 24-month periods," Hammer says. File the patient's contact information based on the month and year when the next screening test is allowed. "For example, if a patient had the bone mass measurement screening in June 2012, the patient's information would be placed in the June 2014 slot." Then pull the information in May of 2014 to review which patients will be eligible for the diagnostic test the next month and either notify them to make an appointment or, if the patient has an appointment already scheduled, mark it on the schedule to perform the scan, says Hammer. Consider including this information in the file: In some cases, you may not know when the patient last had a DXA scan. A call to the payer may help clear the question. But if you cannot locate the date of the previous scan, your office should ask the patient to sign an advance beneficiary notice (ABN). That way, the patient will be responsible for payment if Medicare denies the claim. Monitoring: 3. Count 5 Coverage Categories Five types of beneficiaries who may qualify for covered BMM services are listed in MBPM, Chapter 15, Section 80.5.6: 4. Look Beyond National Policy for ICD-9 For accurate bone scan claims, coders need to become experts on the national coverage determinations (NCDs), local coverage determinations (LCDs), procedure codes, and diagnosis codes affecting their practice, advises Michaeleen OSullivan, BS, CCS, CCS-P, CMT, media director for FreeCodingCEUs.com and owner of Central Business School in Michigan. NCD: The MBPM includes information on beneficiaries who may be covered (see section 3 above), but it does not list covered codes. The MCPM, Chapter 13, Section 140.1, goes into more details about codes. For instance, it supplies the coding information summarized in the table on page 60. Crucial: For instance, WPS Medicare providers can review supporting diagnoses at www.wpsmedicare.com/part_b/policy/active/local/l31620_ms004.shtml. The policy includes a wide range of possible codes, such as 242.00 (Toxic diffuse goiter without thyrotoxic crisis or storm) and 806.4 (Closed fracture of lumbar spine with spinal cord injury). Tip: 5. Stick to Fee Schedule for Payment Information Starting March 1, 2012, Medicare changed how it calculates payments for 77080 (Dual-energy X-ray absorptiometry [DXA], bone density study, 1 or more sites; axial skeleton [e.g., hips, pelvis, spine]), as well as 77082 (... vertebral fracture assessment). Old way: New way:
A woman's treating physician or NPP may use medical history and other findings to decide the patient is estrogen-deficient and at risk for osteoporosis. In that case, she may be BMM-eligible. Even women on estrogen replacement therapy may qualify. The treating practitioner should be sure to document in the "medical record why he or she believes that the woman is estrogen-deficient and at clinical risk for osteoporosis," according to the MBPM.