Medicare Coding of Bone Mass Measurement Procedures

Medicare’s reimbursement system for bone mass measurement relies on Current Procedural Terminology (CPT) Category I codes to consistently identify these services provided to Medicare patients.i These codes are developed and maintained by the American Medical Association (AMA), with input from a number of physician specialty groups. In addition, Medicare utilizes Healthcare Common Procedure Coding System (HCPCS) level II (national) codes to designate other bone mass measurement procedures for reimbursement determination. The agency developed the alphanumeric HCPCS level II coding system to describe and identify many supplies and services that are not included in the CPT coding system. The CPT Category I and HCPCS Level II codes for bone mass measurement procedures are as follows.ⁱⁱ

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Body Composition

Effective for 2003, the AMA also established a new “Category III” code to describe a procedure for assessing body fat composition using dual energy x-ray absorptiometry (DEXA). Category III CPT codes are temporary codes used to report emerging technology, services, and procedures. Use of these codes is considered important for data collection and tracking of emerging technology utilization. According to the AMA, when a Category III code adequately describes a new technology or service, it should be reported rather than reporting a CPT Category I code or an “unlisted” code. (Unlisted codes are used to report services that have not yet been designated with a specific CPT code.) Category III codes may or may not eventually receive a Category I CPT code. In either case, a Category III code will be archived after five years unless it is demonstrated that a temporary code is still needed. The following Category III CPT code has been established for body composition:

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Medicare Coverage of Bone Mass Measurement Procedures

Medicare provides detailed conditions of coverage for bone mass measurement procedures that address the following: type of procedures that will be covered; patients who are eligible to receive the procedure, requirements for providers of the procedure, and the frequency of coverage.

Types of Procedures Covered
Medicare covers bone mass measurement as long as the procedure meets the following criteria:

• Performed on a bone densitometer (other than dual photon absorptiometry – DPA) or a bone sonometer device cleared for marketing by the Food and Drug Administration;
• Performed for the purpose of identifying bone mass or bone loss, or determining bone quality; and
• Includes the physician’s interpretation of the results.

Patients Who Are Eligible for Coverage
Medicare also maintains criteria to determine beneficiaries who are eligible to receive a bone mass measurement procedure:

• Women who are estrogen-deficient and at clinical risk for osteoporosis;
• Individuals with vertebral abnormalities to be indicative of osteoporosis, osteopenia, or vertebral fracture;
• Certain individuals receiving glucocorticoid (steroid) therapy;
• Individuals with primary hyperparathyroidism; or
• Individuals being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy.

Many of Medicare’s contractors have developed local coverage determinations (LCDs) that provide additional details on the specific diagnosis codes that are appropriate for bone mass measurement claims, as well as other pertinent information. To access the bone mass measurement LCD for your area, refer to http://www.cms.hhs.gov/mcd/search.asp?" target or your individual contractor’s website. These policies typically include procedure coding instructions, coverage restrictions, applicable diagnosis codes and documentation requirements. Always consult with your local contractor to determine specific coding and coverage policies for bone mass measurement procedures.

Providers of the Procedure
The procedure must be ordered by the beneficiary’s physician or qualified nonphysician practitioner, following an evaluation of the need for the procedure. The procedure must be furnished by a qualified provider of such services under the appropriate level of physician supervision.

Frequency of Coverage
For those individuals who are eligible, Medicare will pay for a bone mass measurement procedure once every two years, or more frequently if the procedure is determined to be medically necessary. Such exceptions may include patients on long-term steroid therapy of more than three months, or for a confirmatory baseline measurement to permit patient monitoring.

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Medicare Reimbursement for Bone Mass Measurement Procedures

Medicare reimbursement for bone mass measurement procedures is comprised of a professional component, the amount paid for the physician’s interpretation of the results of the scan, and a technical component, the amount paid for all other services (including technician and equipment costs). When combined, this is called the global reimbursement.

A bone mass measurement procedure performed in a physician's office or in a freestanding independent diagnostic testing facility is reimbursed under the Medicare physician fee schedule. In a hospital outpatient department, the technical component of the procedure is reimbursed under an ambulatory payment classification (APC) under Medicare’s hospital outpatient department prospective payment system (OPPS). However, the professional component of the procedure performed in a hospital outpatient department is reimbursed under the Medicare physician fee schedule. Reimbursement amounts for both the Medicare physician fee schedule and the OPPS are updated annually.

Refer to Table 1 for a summary of Medicare average payment amounts for bone mass measurement procedures performed in freestanding facilities and in the hospital outpatient department. For services reimbursed under the Medicare physician fee schedule, the beneficiary is responsible for a copayment amount equal to 20 percent of the total Medicare payment rate. For services subject to the hospital outpatient APC system, the beneficiary copayment amount varies by procedure; this amount is reflected in Table 1.

Medicare payment amounts and coverage policies for specific procedures will vary by geographic location. To obtain more information about local Medicare reimbursement rates for selected bone mass measurement procedures, go to the GE Lunar Medicare Reimbursement Calculator at http://uscpt.gehealthcare.com/us_cpt/bd.jsp and click on the "Reimbursement" icon. To confirm reimbursement rates and coverage requirements, you should consult your local carrier or fiscal intermediary for specific codes.

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Reimbursement by Other Payers

Reimbursement policies of private payers will vary, depending on a variety of factors including location, payment arrangements, patient volume, etc. While some private payers may rely on Medicare reimbursement amounts as the basis for their reimbursement policies, many others may consider alternative information. You should consult with individual payers for more information on coding for reimbursement. Finally, Medicaid program reimbursement rates and methods also will vary across states.

ⁱ CPT codes and descriptions only are copyright © 2003 American Medical Association. All rights reserved. No fee schedules are included in CPT. The American Medical Association assumes no liability for data contained or not contained herein.

ⁱⁱ Refer to the following sources: 42 CFR §410.31 Bone mass measurement: Conditions for coverage and frequency standards; Medicare Intermediary Manual, Part 3, §3631. HCPCS for Hospital Outpatient Radiology Services and Other Diagnostic Procedures; and Medicare Carriers Manual, Part 3, §4181.1 Conditions of Coverage.

ⁱⁱⁱ Medicare Physician Fee Schedule amounts are for calendar year 2004, with relative value units (RVUs) as published in the Federal Register, vol. 68, no. 216, November 7, 2003; amended RVUs in the Federal Register, vol. 69, no. 4, January 7, 2004. Medicare hospital outpatient APC amounts are for calendar year 2004, as published in the Federal Register, vol. 68, no. 216, November 7, 2003; amended in Federal Register, vol. 69, no. 3, January 6, 2004. Third party reimbursement amounts and coverage policies for specific procedures will vary by payer and by locality. Information presented above is representative of 2004 Medicare national average professional and technical payment amounts for participating facilities, hospital outpatient departments, or mobile units. Amounts do not necessarily reflect any subsequent changes in payment since publication. To confirm reimbursement rates, you should consult with your local carrier or fiscal intermediary for specific codes.

^iv Represents the national unadjusted copayment amount for the APC, which cannot exceed 50 percent of the Medicare APC payment rate in CY 2004. For certain APCs, hospitals may elect to reduce copayment amounts to a level no less than the minimum unadjusted copayment amount for the APC. The copayment amount for some APCs is based on the minimum (rather than the national) unadjusted copayment amount. The Hospital Outpatient Reimbursement Amount is the total payment to the hospital regardless of the applicable copayment amount. The copayment amount is used to determine how much of the Hospital Outpatient Reimbursement Amount will be paid by Medicare and the beneficiary. Hospital outpatient copayment amounts are effective as of January 1, 2004 as published in the Federal Register, vol. 68, no. 216, November 7, 2003; amended in Federal Register, vol. 69, no. 3, January 6, 2004. The beneficiary copayment amount for Medicare Part B services, including those reimbursed on the basis of the physician fee schedule equals 20% of the Medicare payment rate.

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