CPT 77085 Bone mineral density studies
Bone (mineral) density studies are used to evaluate diseases of bone and/or the responses of bone diseases to treatment. The studies access bone mass or density associated with such diseases as osteoporosis, osteomalacia, and renal osteodystrophy. Various single or combined methods of measurement may be required to: (a) diagnose bone disease, (b) monitor the course of bone changes with disease progression, or (c) monitor the course of bone changes with therapy.
Covered methods for measuring bone mineral density include:
• Single energy x-ray absorptiometry (SEXA)
• Dual energy x-ray absorptiometry (DXA)
• Quantitative computed tomography (QCT)
• Bone ultrasound densitometry (BUD)
• Photodensitometry
• Radiographic absorptiometry (RA)
The following bone mass measurements are NOT covered under Medicare because they are not considered reasonable and necessary under section 1862(a)(1)(A) of the Act:
• Single photon absorptiometry (SPA), CPT code 78350 (effective 01/01/2007)
• Dual photon absorptiometry (DPA), CPT code 78351.
Bone density can be measured at the wrist, spine, hip or calcaneus. The medical literature is divided on the accuracy of predicting osteoporosis of the spine or hip by measuring peripheral sites (wrist, calcaneus). It does appear, however, that measurement of bone density of the bone involved gives a better measurement of osteoporosis than does measurement of another bone not known to be involved.
Precise calibration of the equipment is required for accuracy and to reduce variation of test results and risk of misclassification of the degree of bone density. Lack of standardization in bone mineral measurement remains an issue, and tests are best done on the same suitably precise instrument to insure accuracy. It is important to use results obtained with the same scanner when comparing a patient to a control population, as systematic differences among scanners have been found. To ensure reliability of bone mass measurements, the densitometry technologist must have proper training in performing this procedure. Malpositioning of a patient or analyzing a scan incorrectly can lead to great errors in bone mineral density studies.
Indications:
Medicare considers a bone mineral density study to be medically reasonable and necessary for the following indications. In addition, all coverage criteria listed below must be met.
1. A patient with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral fracture.
2. A patient being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy. This service must be performed using dual energy x-ray absorptiometry system (axial skeleton) – CPT codes 77080 and 77085.
3. A patient with known primary hyperparathyroidism.
4. A patient receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg of prednisone or greater, per day, for more than 3 months.
5. A woman who has been determined by the physician or a qualified non physician practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings.
NOTE: Since not every woman who has been prescribed estrogen replacement therapy (ERT) maybe receiving an “adequate” dose of the therapy, the fact that a woman is receiving ERT should not preclude her treating physician or other qualified treating nonphysician practitioner from ordering a bone mass measurement for her. If a bone mass measurement is ordered for a woman following a careful evaluation of her medical need, however, it is expected that the ordering/treating physician (or other qualified treating nonphysician practitioner) will document in her medical record why he or she believes that the woman is estrogen-deficient and at clinical risk for osteoporosis.
An estrogen-deficient woman qualifies if she is at clinical risk for osteoporosis, based on her medical history and other findings. Unless this applies and is documented in the medical record, the service is not payable.
In addition to gender and estrogen-deficiency, pertinent factors acceptable as documentation for the clinical risk include, but are not limited to: age, family history and personal history of fractures as an adult, race, bone structure and body weight, premature menopause, lifestyle, medications, chronic diseases, and other genetic and environmental factors. Symptoms and findings of osteoporosis include, but are not limited to: back pain, loss of height, curving spine, and chest x-ray showing osteopenia.
Bone density measurement is not a covered Medicare benefit when utilized for osteoporosis screening in an estrogen-deficient woman, who has not been determined by the physician or a qualified nonphysician practitioner treating her to be at clinical risk for osteoporosis, based on her medical history and other findings.
If - in addition to gender and estrogen-deficiency - a woman has been determined to be at clinical risk for osteoporosis, based on her history and other findings, and this has been appropriately documented in the medical record, this Carrier will interpret the menopausal state as symptomatic.