why wont medicare cover 77080

by Antonietta Rempel Published 2 years ago Updated 2 years ago

77080 replaces 76075 • BMM is not covered when a procedure other than dual-energy x-ray absorptiometry is used to monitor osteoporosis drug therapy. Therefore, Medicare will not pay for procedure codes 76977, 77078, 77079, 77081, 77083 and G0130 when billed with the following ICD-9-CM diagnosis codes:

Full Answer

Are screening DEXA scans CPT 77080 allowed for osteoporosis?

Hello, we are receiving denials for screening dexa scans CPT 77080 with diagnosis Z13.820 screening for osteoporosis. Per Medicare article MM5521, screenings are allowed every 2 years, but we are being denied. The denial is for NCD, as Medicare NCD 150.3 does not list the Z screening code. Any help would be greatly appreciated.

Does Medicare pay for procedure codes 76977 and 77078?

• BMM is not covered when a procedure other than dual-energy x-ray absorptiometry is used to monitor osteoporosis drug therapy. Therefore, Medicare will not pay for procedure codes 76977, 77078, 77079, 77081, 77083 and G0130 when billed with the following ICD-9-CM diagnosis codes: 733.00 733.01 733.02 733.03 733.09 733.90 255.0

Should I resubmit CPT code 77080?

I would appreciate any advice. If 77080 is an age-specific CPT code, then verify correct DOB on claim, or if recurring denial reason, then verify payer has correct age and DOB. So correct and resubmit.

Does Medicare cover DEXA scans?

In most cases, Medicare insurance does cover DEXA scans under Part B. Medicare Part B (Medical Insurance) provides benefits for outpatient procedures that are deemed medically necessary for ongoing treatment of illness. A DEXA scan will need to be ordered by your doctor in order...

Does Medicare cover 77080?

Effective for dates of service on or after January 1, 2007, Medicare will pay for BMM services for dual-energy x-ray absorptiometry (CPT code 77080) when this procedure is used to monitor osteoporosis drug therapy.

Are bone density scans covered under Medicare?

The full cost of a bone density scan is covered under original Medicare every 24 months. If you need to have a bone density test more often, your doctor will have to provide proof of a reason for more frequent testing.

What diagnosis covers CPT 77080?

Group 1. * Per CMS IOM Publication 100-04, Chapter 13, Section 140.1, CPT code 77080 or CPT code 77085 is covered when used to monitor FDA-approved osteoporosis drug therapy subject to the 2-year frequency standards described by CMS IOM Publication 100-02, Chapter 15, Section 80.5.

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.

How often will Medicare pay for a bone density scan?

once every 24 monthsBone mass measurements 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 ICD 10 code covers DEXA scan for Medicare 2021?

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.

How often can CPT 77080 be billed?

Tests not ordered by the physician/qualified non-physician practitioner, who is treating the beneficiary, are not reasonable and necessary. sites studied (e.g., if the spine and hip are studied, CPT code 77080 should be billed only once).

What does CPT code 77080 mean?

Code. Description. 77080. DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE)

What diagnosis code will Medicare cover for a DEXA scan?

Medicare beneficiaries who meet the above criteria may have a Diagnostic DXA once every 24 months (more often if medically necessary)....Updated DXA Policy for Medicare Patients.Z78.0Asymptomatic menopausal stateZ87.310Personal history of (healed) osteoporosis fracture4 more rows•Mar 6, 2017

Which of the following services is not typically covered by Medicare?

does not cover: Routine dental exams, most dental care or dentures. Routine eye exams, eyeglasses or contacts. Hearing aids or related exams or services.

How often should you have a bone density scan if you have osteoporosis?

How often should I have a bone mineral density test? How often you should have your BMD measured depends on your age and results of your previous DEXA scan. Women 65 years and older with normal bone mass or mild bone loss can have a test every 15 years.

Does Medicare cover physical therapy for osteoporosis?

Medicare Part B generally covers physical therapy services. If you get physical therapy at the hospital, an outpatient center, or in your doctor's office, Part B typically covers 80% of allowable charges after you meet your Part B deductible.

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.

What is the cost of a bone density test?

Typical costs: For patients not covered by health insurance, the typical cost of a bone density test, including a doctor consultation to explain the results, is about $150 to $250.

How much does a bone density scan cost in Australia?

The cost of a bone mineral density test ranges from $85 to $160.

What diagnosis codes cover bone density?

77080CodeDescriptionM85.841Other specified disorders of bone density and structure, right handM85.842Other specified disorders of bone density and structure, left handM85.851Other specified disorders of bone density and structure, right thighM85.852Other specified disorders of bone density and structure, left thigh124 more rows

When medical records are requested, are letters of support and/or explanation useful?

When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included. System coding changes.

Can Medicare pay for 77080?

The basic clarification is that Medicare allows codes other than CPT code 77080 (i.e., 76977, 77078, 77079, 77081, 77083, and G0130) to be paid even though claims for such services report both a screening diagnosis code and an osteoporosis code.

Document Information

CMS National Coverage Policy

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Bone Mineral Density Studies. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy.

Coverage Guidance

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.

General Information

Article Guidance

This First Coast Billing and Coding Article for Local Coverage Determination (LCD) L36356 Bone Mineral Density Studies provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials.

ICD-10-CM Codes that Support Medical Necessity

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim (s) submitted.

ICD-10-CM Codes that DO NOT Support Medical Necessity

All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this article.

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.

Summary of Findings

Since the initiation of the review, 193 claims were reviewed from November 29, 2020 through May 24, 2021. The breakdown of those findings are as follows:

Education

When the MAC requests documentation for review, it is the provider’s responsibility for the requested documentation to be received within 45 calendar days from the request. The MAC will not grant extensions to providers who need more time to comply with the request.

Summary

This service specific targeted review will continue until medical review results demonstrate provider compliance with Medicare guidelines and education provided. This file is reviewed at least quarterly; providers with low/no errors after a reasonable sample will no longer be reviewed for this file. Remaining providers will continue to be reviewed.

What does Medicare Part B cover?

Part B also covers durable medical equipment, home health care, and some preventive services.

Does Medicare cover tests?

Medicare coverage for many tests, items, and services depends on where you live . This list includes tests, items, and services (covered and non-covered) if coverage is the same no matter where you live.

How often does Medicare cover bone mass?

Medicare may cover a bone mass measurement for a beneficiary once every two years (if at least 23 months have passed since the month the last bone mass measurement was performed). Examples of situations where more frequent bone mass measurements may be medically necessary include, but are not limited to, the following medical circumstances:

Why are patients being monitored for osteoporosis?

Patients who are being monitored because of medications that have a high likelihood of causing osteoporosis. Note: Patients who will be placed on long-term glucocorticoid (steroid) therapy (e.g., transplant patients) should have a baseline axial bone mass measurement performed after beginning use of the medication.

Can Medicare reimburse for bone mass?

Medicare reimbursement for a bone mass measurement, whether done by, DEXA, RA, QCT, SEXA or sonometry, is allowed only once on a given date, no matter how many sites are studied at that time. Two examples are as follows:

Do CPT codes have long descriptors?

Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.

Do you need a dexa scan?

A DEXA scan will need to be ordered by your doctor in order to be covered, and although rare, some conditions may require a patient and his or her physician to work through other treatment options prior to undergoing a DEXA scan.

Does Medicare cover dexa scans?

In most cases, Medicare insurance does cover DEXA scans under Part B. Medicare Part B ( Medical Insurance) provides benefits for outpatient procedures that are deemed medically necessary for ongoing treatment of illness. A DEXA scan will need to be ordered by your doctor in order to be covered, and although rare, ...

Can you take medication after a dexa scan?

This may also be the case when a Medicare recipient needs to recuperate after an operation subsequent to cancer treatment and bone health has been negatively affected by the disease or treatment. After a DEXA scan, you may also need to take medications to improve bone and overall health.

Can you get a dexa scan with Medicare?

In addition to receiving a DEXA scan under Medicare Part B, you may also be able to receive coverage through Medicare Part A (Hospital Insurance) if a DEXA scan is performed during a required stay at a certified skilled nursing facility .

Can a dexa scan show a fracture?

This, in turn, offers medical providers the chance to see where damage has been done due to conditions like osteoporosis, but a DEXA scan can also show trouble spots where healing is or is not taking place after a fracture or break.