If CMS determines that a bone mass measurement does not meet the conditions for coverage in paragraphs (b) or (d) of this section, or the standards on frequency of coverage in paragraph (c) of this section, it is excluded from Medicare coverage as not “reasonable” and “necessary” under section 1862 (a) (1) (A) of the Act and § 411.15 (k) of this chapter.
Full Answer
Does Medicare cover bone mass measurements?
Bone mass measurements. Medicare Part B (Medical Insurance) covers this test once every 24 months (or more often if medically necessary) if you meet one of more of these conditions: You’re a woman whose doctor determines you’re estrogen deficient and at risk for osteoporosis, based on your medical history and other findings.
What does Medicare Part B cover?
Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services. You’re a woman whose doctor determines you’re estrogen deficient and at risk for osteoporosis, based on your medical history and other findings.
How does Medicare pay for osteoporosis drug therapy?
You’re being monitored to see if your osteoporosis drug therapy is working. An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance. .
Is bone mass measurement covered by Medicare?
Bone mass measurements (also called bone density tests) can help determine if you need medical treatment for osteoporosis, a condition that can cause brittle bones in older adults. Medicare Part B covers bone mass measurement every two years if you are at risk for osteoporosis and have a referral from your provider.
Is Z13 820 covered by Medicare?
Medicare will always deny Z13. 820 if it is the primary or only diagnosis code.
Is prolia covered by Medicare Part B or Part D?
For those who meet the criteria prescribed above, Medicare Part B covers Prolia. If you don't meet the above criteria, your Medicare Part D plan may cover the drug. GoodRx reports that 98% of surveyed Medicare prescription plans cover Prolia. With Medicare Part D coverage, you're likely to pay coinsurance or a copay.
What diagnosis will Medicare cover for a DEXA scan?
osteoporosisMedicare will cover bone density scans for a person who meets certain medical requirements, such as osteoporosis risk factors. Identifying thinning bone or osteoporosis at early stages before a person breaks a bone can allow them to receive treatments that may help reduce the risk of broken bones.
Does Medicare cover Z01 818?
From what I understand, Medicare will not cover Z01. 818 (encounter for other preprocedural exam).
What ICD-10 code covers bone density for Medicare?
(L34639) Bone Mass Measurement ICD-10 Codes That Support Medical Necessity and Covered by Medicare Program: Group 1 Paragraph: Note: ICD-10 codes must be coded to the highest level of specificity.
Is Boniva injection covered by Medicare?
Yes. 99% of Medicare prescription drug plans cover this drug.
Does Medicare Part D pay for Prolia?
The average out-of-pocket (OOP) cost for Prolia® through Medicare Part D is $115‡ every 6 months, which equals $19.16 per month. For patients with limited income: Medicare beneficiaries may qualify for Extra Help, a program to help pay for medication costs through Medicare Part D.
Is Reclast covered by Medicare Part D?
Medicare's Part D prescription drug benefit typically provides coverage for drugs that can be dispensed through retail pharmacies. Because Reclast is provided as an injection and not a medication that can be purchased at a traditional pharmacy, Medicare Part D insurance generally does not cover Reclast.
What ICD-10 code covers screening DEXA scan for Medicare?
ICD-10 CM code Z79. 83 should be reported for DXA testing while taking medicines for osteoporosis/osteopenia. ICD-10 CM code Z09 should be reported for an individual who has COMPLETED drug therapy for osteoporosis and is being monitored for response to therapy.
Does Medicare cover a nuclear bone scan?
Description Information. Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service. Nuclear radiology procedures, including nuclear examinations performed with mobile radiological equipment, are covered if reasonable and necessary for the individual patient.
Is a DEXA scan a bone scan?
A bone density scan uses low dose X-rays to see how dense (or strong) your bones are. You may also hear it called a DEXA scan. Bone density scans are often used to diagnose or assess your risk of osteoporosis, a health condition that weakens bones and makes them more likely to break.
What is part B of bone mass?
Bone mass measurements. Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services. You’re a woman whose doctor determines you’re estrogen deficient and at risk for osteoporosis, based on your medical history and other findings.
What type of fractures can be seen on X-rays?
Your X-rays show possible osteoporosis, osteopenia, or vertebral fractures. You’re taking prednisone or steroid-type drugs or are planning to begin this treatment. You’ve been diagnosed with primary hyperparathyroidism. You’re being monitored to see if your osteoporosis drug therapy is working.
How often does Medicare pay for BMM?
Medicare pays for a screening BMM once every 2 years with a few exceptions for more frequent testing. Section 80.5.6 of the above referenced manual, states that Medicare covers the screening for the following:
What are the positives of having a broken bone?
Another positive was that broken bones generally heal quickly and effectively in the young. Recovering from broken bones when you are older is harder ...
How many people have osteoporosis?
According to the Centers for Disease Control (CDC) website, osteoporosis “affects about 25% (1 in 4) of women aged 65 and over and about 5% (1 in 20) of men aged 65 and over. Many people with osteoporosis do not know they have it until they break a bone. Screening is important to find these people before this happens, ...
Does Medicare cover bone mass?
The good news for older Americans is that Medicare covers bone mass measurements to screen for osteoporosis as one of their preventive services. This means the beneficiary co-pay and deductible are waived so Medicare bears all the cost of these screenings. The coverage guidelines for bone mass measurements ...
Is CPT code 78350 covered by Medicare?
Single photon absorptiometry tests are not covered. Contractors will deny CPT procedure code 78350. As you age take care of your bone health by taking your calcium and vitamin D, eating well, and doing strength exercises. As a Medicare provider, avoid denials by including the correct diagnosis codes on your claims for bone mass measurements.
Document Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
CMS National Coverage Policy
Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy.
Coverage Guidance
Bone mass measurement (BMM) studies are radiologic, radioisotopic or other procedures that meet all of the following conditions:
How often does Medicare cover bone mass?
Medicare Part B covers bone mass measurement every two years if you are at risk for osteoporosis and have a referral from your provider. Medicare considers you at risk if you: Are an estrogen-deficient women who is at risk for osteoporosis based on your medical history and other findings.
Does Medicare cover bone mass measurements?
Medicare Advantage Plans are required to cover bone mass measurements without applying deductibles, copayments, or coinsurance when you see an in-network provider and meet Medicare’s eligibility requirements for the service.
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L36460-Bone Mass Measurement.
ICD-10-CM Codes that Support Medical Necessity
It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
What is bone mass measurement?
Bone mass measurement means a radiologic, radioisotopic, or other procedure that meets the following conditions: (1) Is performed for the purpose of identifying bone mass, detecting bone loss, or determining bone quality. (2) Is performed with either a bone densitometer (other than single-photon or dual-photon absorptiometry) ...
Does Medicare cover bone mass?
Except as allowed under paragraph (c) (2) of this section, Medicare may cover a bone mass measurement for a beneficiary if at least 23 months have passed since the month the last bone mass measurement was performed. (2) Exception. If medically necessary, Medicare may cover a bone mass measurement for a beneficiary more frequently than allowed ...