Oncology & Hematology Coding Alert

Be prepared with these 5 tips on orders, frequency, coverage, and more.

Prednisone may be helpful for reducing inflammation and its related pain in cancer patients, but it can also lead to bone loss. If your practice provides bone mass measurement (BMM) services for Medicare patients, these 5 tips should help keep your claims compliant.

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:

• Physician assistants
• Nurse practitioners
• Clinical nurse specialists
• Certified nurse midwives.

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 manage the patient's care, 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: If the patient is having a screening, Medicare will pay for BMM once every 2 years (at least 23 months have passed since the month the last covered BMM was performed), states MBPM, Chapter 15, Section 80.5.4.

Example: The beneficiary received a bone mass measurement in January 2009. The count starts February 2009. The beneficiary is eligible to receive another bone mass measurement in January 2011 (the month after 23 months have passed), according to The Guide to Medicare Preventive Services (www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_guide_web-061305.pdf).

Practical solution: Some practice management software and/or EMR programs have some type of 'reminder' or patient notice feature. It often can be set up to either create a report with patient contact information or even send out automatic notices to the patients that meet the criteria for the specific reminder notice, i.e., immunizations, preventive services, or any other screening testing, says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver, Colo.

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:

• Jane Doe
• Date of Birth:
• Practice ID #:
• Telephone #:

Date of last BMM screen:

Prior to performing the scan, verify with the patient whether she has had another scan by a different provider since the last known date of the DXA performed by your group. 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.

Exception: Medicare may pay for BMMs more frequently than every two years if documentation shows medical necessity. Medicare gives the following examples:

Monitoring beneficiaries on long-term glucocorticoid (steroid) therapy of more than 3 months Confirming baseline BMMs to permit monitoring of beneficiaries in the future.

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:

Osteoporosis risk: 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.

Vertebral abnormality: A patient with X-ray results that indicate osteoporosis, osteopenia, or vertebral fracture may have a covered BMM.

Hyperparathyroidism: BMM coverage applies to beneficiaries with primary hyperparathyroidism.

Steroid therapy: Patients receiving (or expecting to receive) glucocorticoid therapy are eligible for BMM coverage. To qualify, the patient's dosage must be equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than 3 months.

Monitoring: Medicare covers BMM to monitor a patient's response to FDA-approved osteoporosis therapy.

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: Medicare's National Coverage Determination (NCD) for BMM instructs you to see MBPM, Chapter 15, Section 80.5, for coverage conditions and Medicare Claims Processing Manual (MCPM), Chapter 13, Section 140, for claims processing instructions (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c13.pdf).

The MBPM includes information on beneficiaries who may be covered (see section 3 above), but it does not list covered codes.

MCPM, Chapter 13, Section 140.1, goes into more details about codes. For instance, it supplies the coding information summarized in the table in BMM Coverage on page 78.

Crucial: Pay particular attention to the ICD-9-CM requirement for screening. The MCPM indicates that to find ICD-9-CM codes that support medical necessity you'll need to check your local contractor's policy.

For instance, WPS Medicare providers can review supporting diagnoses in LCD L31620. The policy includes a wide range of possible codes, such as 256.31 (Premature menopause) and V58.65 (Long-term [current] use of steroids).

Tip: Don't limit your local policy review to the covered codes. The policy may include additional instructions for your claim. As an example, WPS directs the use of specific V codes if the patient meets certain conditions (such as V45.77, Acquired absence of organ genital organs, for women who are status/post oophorectomy).

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: Beginning in 2010, as part of the Affordable Care Act, Medicare calculated DXA payment as equal to 70 percent of the product of the (a) relative value for the service for CY 2006; (b) the conversion factor for CY 2006; and (c) the geographic adjustment factor for the service for the fee schedule area (payment locality) for CYs 2010 and 2011, respectively.

New way: Effective March 1, 2012, Medicare bases 77080 and 77082 payment on standard physician fee schedule calculations. That means multiplying the 2012 relative value units (RVUs) by the conversion factor and the geographic adjustment factor. This information is available in MLN Matters article MM7767: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7767.pdf.