Internal Medicine Coding Alert

Published on Tue Sep 01, 1998 PDF

New HCPCS codes covering the bone mass measurements absorptionmetry and computed tomography (CT) are enabling internal medicine practices to get paid for yet another preventive medicine service previously denied coverage by Medicare and most private third-party payers. Coverage of these screening tools is expected to allow practices to accurately screen more patients for bone disorders like osteoporosis, and provide incentives for monitoring the efficacy of treatment for these conditions.

The advent of additional coverage for bone mass measurement will greatly benefit the internal medicine specialty because it eases the financial burden on internists to perform a needed diagnostic tool and permits reimbursement at an acceptable level, predicts Don Self, president of Don Self and Associates, a practice management consulting firm in Whitehouse, TX.

The Balanced Budget Act (BBA) of 1997 provides for uniform coverage of bone mass measurements for certain Medicare beneficiaries. Prior to the BBAs enactment, Medicare coverage of bone density measurements was limited to a diagnostic x-ray and a limited number of other clinical and laboratory tests, and only covered services reasonable and necessary for the diagnosis or treatment of illness.

In recent years, new bone mass measurements have been developed and gained acceptance in the medical community, states the introduction to the Health Care Financing Administration (HCFA) final rule detailing the new payments and coverage requirements. Since they have not been excluded under section 50-44 of [Medicares Coverage Issues Manual], most Medicare contractors had begun to pay for the medically necessary use of these measurements, but some Medicare contractors have not.

As a result, Medicare coverage has been inconsistent, the statement notes.

Note: The complete text of HCFAs interim final rule can be found in the Federal Register, Volume 63, No. 121, Wednesday, June 24, 1998.

Under the new policy, HCFA has released several new codes and revised others to expand Medicares coverage of the screening tools. In addition, the tests will be covered both as a preventive screening tool for diagnosing the risk of osteoporosis or osteodystrophy, and as a tool for measuring the success of treatment achieved in these patients.

Who is Eligible?

HCFA has defined five categories of individuals who should receive uniform coverage of bone mass measurement tests. Internists should be aware of which of their patients are eligible when they consider performing or ordering these tests. These five categories are:

1. An estrogen-deficient woman at clinical risk for osteoporosis. Clinical risk has been defined as a woman who has been determined by the physician (or a qualified non-physician practitioner) treating her to be estrogen-deficient and at risk for osteoporosis, based on medical history or other findings.

2. An individual with vertebral abnormalities. The abnormalities should be demonstrated by x-ray to be indicative of osteoporosis, low bone mass (osteopenia), or vertebral fracture.

3. An individual receiving long-term glucocorticoid (steroid) therapy. The individual must be receiving therapy equivalent to 7.5 mg of prednisone or greater, per day for more than three months.

4. An individual with primary hyperparathyroidism.

5. An individual being monitored to assess the response to, or efficacy of, an approved osteoporosis drug therapy.

What Tests Are Covered?

This is a list of the tests that will be covered by Medicare, along with their procedure codes.

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

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

76078-Radiographic absorptionmetry (photodensitometry), one or more sites

78350-Bone density (bone mineral content) study, one or more sites; single-photon absorptionmetry.

G0130-Single-energy x-ray absorptionmetry (SEXA) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel).

G0131-Computerized tomography bone mineral density study, one or more sites, axial skeleton (e.g. hips, pelvis, spine).

G0132-Computerized tomography bone mineral density study, one or more sites, appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

G0133-Ultrasound bone mineral density study, one or more sites, appendicular skeleton (peripheral) (e.g., radius, wrist, heel.)

Internal medicine coders should note that the G codes are for Medicare use only and the numeric codes can be used with all carriers, says Self.

We also caution internists to make sure they not only document the actual test in their charts, but, even more importantly, the medical necessity of each test, should your records be later requested in an audit or review, he adds.

Frequency Standards

In general, says Self, coverage for follow-up bone mass measurements will be limited to only one measurement every two years for beneficiaries who receive coverage.

Follow-up measurements performed more frequently may be covered when medically necessary, he adds. Medically necessary exceptions would include:

1) measurements to monitor beneficiaries on long-term glucocorticoid therapy, who have been on the therapy more than three months; and,

2) measurements performed to allow a confirmatory baseline bone mass measurement to permit monitoring of the beneficiary in the future, if the initial test was performed with a technique that is different from the proposed monitoring method.

"For example, he explains. if the initial test (diagnosing a condition) were performed using bone sonometry and monitoring is anticipated using bone densitometry, Medicare will allow coverage of a baseline measurement using bone densitometry..