Accurate billing and coding are crucial for healthcare providers, especially when dealing with Medicare claims. This guide provides essential information for navigating the complexities of billing for bone density scans, officially known as Bone Mass Measurement (BMM), with a specific focus on diagnosis codes and related guidelines under local coverage policy L36460. Understanding these guidelines is vital to ensure proper reimbursement and avoid claim denials.
Understanding Medicare Billing Guidelines for Bone Density Scans
To successfully bill Medicare for bone density scans, several key guidelines must be followed. These encompass general claim submission, the use of Advance Beneficiary Notices (ABNs), and appropriate coding practices.
General Claim Submission Requirements and ICD-10-CM Diagnosis Codes
When submitting claims to Medicare Administrative Contractors (MACs), whether Part A or Part B, it’s imperative to adhere to National Correct Coding Initiative (NCCI) edits and Outpatient Prospective Payment System (OPPS) packaging edits. Always consult NCCI and OPPS guidelines before billing. For services that require a referring or ordering physician, ensure their name and National Provider Identifier (NPI) are clearly stated on the claim.
A critical aspect of claim submission is the inclusion of a valid ICD-10-CM diagnosis code. Medicare mandates that claims lacking a valid diagnosis code will be rejected as incomplete. The diagnosis code, or codes, you provide must precisely reflect the patient’s condition that necessitated the bone density scan. For diagnostic tests like BMM, if the results are available, report them. If not, detail the symptoms that prompted the test. This ensures medical necessity is clearly justified through appropriate diagnosis coding.
Advance Beneficiary Notices (ABN) and Modifier Usage
In situations where a bone density scan service might not be covered by Medicare, an Advance Beneficiary Notice of Non-coverage (ABN) may be necessary. This is particularly relevant when non-coverage is anticipated due to medical necessity issues or other reasons. For comprehensive instructions on ABNs, refer to Chapter 30 of the CMS Publication 100-04, Medicare Claims Processing Manual.
Effective April 1, 2010, specific modifiers are required for billing non-covered services. These modifiers, –GA, -GX, -GY, or –GZ, help indicate the circumstances of potential non-coverage.
The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) is used when you anticipate Medicare denying a service as not reasonable and necessary and have a signed ABN from the patient. This modifier applies only when denial is expected under sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act, related to reasonable and necessary provisions. When billing with the GA modifier, be aware that Part A MAC systems will automatically deny these services. A signed ABN, Form CMS-R-131, confirms the beneficiary’s agreement to financial responsibility. In cases where a patient refuses to sign the ABN, the -GA modifier can still be used on assigned claims if the refusal is properly witnessed. For Part A MAC claims with a GA modifier, occurrence code 32 and the ABN date are mandatory.
Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) is used when an ABN is signed, and denial is expected for reasons other than medical necessity. These reasons can include statutory exclusions or technical issues. While an ABN isn’t mandatory for these denials, using modifier GX with non-covered services will result in automatic denial.
The –GZ modifier is applied when you expect Medicare to deny a service as not reasonable and necessary, but you do not have a signed ABN from the patient. Conversely, if a service is statutorily non-covered or lacks a benefit category, use the -GY modifier with the appropriate CPT/HCPCS code. Neither ABNs nor limitation of liability apply to services billed with -GY, and these claims will also be automatically denied.
Key Documentation for Bone Density Scan Claims
Thorough and accurate documentation is paramount for successful Medicare claims for bone density scans. The patient’s medical record must comprehensively justify the medical necessity of the test and the services provided.
Essential Medical Record Elements
The medical record should include, but is not limited to, the following elements:
- Assessment by the Ordering Provider: Detail the ordering provider’s assessment of the patient’s condition, specifically related to their presenting complaint during the visit.
- Relevant Medical History: Include pertinent medical history that supports the need for a bone density scan. This might include risk factors for osteoporosis, previous fractures, or relevant medical conditions.
- Results of Pertinent Tests/Procedures: Document the results of any prior tests or procedures that informed the decision to order a bone density scan.
- Signed and Dated Records: Ensure all office visit records and operative reports are signed and dated by the rendering provider. Medicare requires signatures for all services ordered or provided to beneficiaries.
It’s important to note that older technologies like single and dual photon absorptiometry, represented by CPT codes 78350 or 78351, are no longer utilized and are not covered by Medicare.
Coverage Limitations for Bone Density Measurements
Medicare has specific limitations regarding the coverage of bone density measurements to ensure appropriate utilization and prevent unnecessary testing. Understanding these limitations is crucial for providers.
Reasons for Non-Coverage
Several circumstances can lead to non-coverage of bone density scans:
- Tests Not Ordered by Treating Physician/Qualified Practitioner: Bone density scans must be ordered by the physician or qualified non-physician practitioner who is actively treating the beneficiary. Tests ordered by other providers are deemed not reasonable and necessary.
- Frequency Limits for Initial Bone Mass Measurement: Medicare typically reimburses for an initial bone mass measurement only once in a lifetime, regardless of the skeletal sites studied. For example, if both spine and hip are scanned, CPT code 77080 should be billed only once for the initial test.
- Duplication of BMM Types: Performing more than one type of bone mass measurement test on the same individual is generally not medically necessary. An exception is a confirmatory DXA test performed as a baseline for future monitoring in specific clinical scenarios.
- Concurrent Axial and Peripheral BMM Tests: It is not considered medically necessary to perform both peripheral and axial bone mass measurement tests on the same day.
- Repeat BMM Tests by Second Providers: Medicare will not reimburse for BMM tests performed by a second provider if a test has already been conducted within the defined coverage period, unless it’s a confirmatory test for future monitoring. Beneficiaries should authorize providers to share prior test results. Documented unsuccessful attempts to obtain prior results may justify reimbursement for new tests.
- Non-Covered Technologies: Single and dual photon absorptiometry (CPT codes 78350 and 78351) are specifically non-covered services.
- Portable X-ray Benefit Exclusion: Bone mass measurement is not covered under the portable x-ray benefit and will be denied if performed by a portable x-ray supplier. Transportation charges for BMM testing are also not covered.
- Lack of Interpretation and Report: Bone mass measurement tests must include an accompanying interpretation and report to be considered medically necessary. The report must be separate and distinct from an evaluation and management note or record.
Specific CPT Code 77082 and Vertebral Fracture Assessment
CPT code 77082 is specifically for vertebral fracture assessment and is not considered a bone density study by Medicare. Therefore, it should not be billed for bone density screening. Code 77082 can be billed when medically necessary, specifically when a vertebral fracture assessment is clinically indicated. Symptoms necessitating this assessment should be present and documented, with the expectation that the test results will directly influence patient management.
Conclusion
Accurate diagnosis coding and adherence to Medicare’s billing and coding guidelines are essential for healthcare providers offering bone density scans. By understanding the nuances of ICD-10-CM coding, ABN modifiers, documentation requirements, and coverage limitations, providers can ensure compliant billing practices, minimize claim denials, and receive appropriate reimbursement for these vital diagnostic services. Prioritizing accurate and thorough documentation, especially clear justification for medical necessity through precise diagnosis coding, is the cornerstone of successful bone density scan billing under Medicare.
