Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) will implement Change Request (CR) 9252 on January 4, 2016, effective October 1, 2015. (See related MLN Matters® article MM9252.) This CR establishes the list of covered conditions and corresponding ICD-10-CM diagnosis codes approved for Bone Mass Measurement studies according to the requirements set forth in National Coverage Determination (NCD) 150.3. CR9252 and accompanying spreadsheet inadvertently omitted the condition of osteopenia and the ICD- 10-CM codes that describe it which are classified to subcategory M85.8- Other specified disorders of bone density and structure. The codes and conditions identified within this subcategory are considered covered indications for bone mass measurement under NCD 150.3 and providers should report these appropriately according to medical documentation.
Additional guidance and education as to the updated complete list of covered indications will be forthcoming as CMS continues to review this issue and the systems updates required. Under ICD-9-CM, the term “Osteopenia” was indexed to ICD-9-CM diagnosis code 733.90 (Disorder of bone and cartilage). This code was listed as a covered condition under the Business requirement 5521.1.1 for CR 5521/NCD 150.3, dated May 11, 2007, when reported with CPT code 77080. (See related MLN Matters article MM552
Under ICD-10-CM, the term “Osteopenia” is indexed to ICD-10-CM subcategory M85.8- Other specified disorders of bone density and structure, within the ICD-10-CM Alphabetic Index. The codes within this subcategory were inadvertently omitted from the CMS spreadsheet that accompanied CR 9252 containing the list of covered conditions and corresponding diagnosis codes. These are considered covered for NCD 150.3 indications.
Below is the list of ICD-10-CM diagnosis codes within subcategory M85.8- that providers may report as covered indications in addition to the current list provided in CR 9252 and its accompanying CMS spreadsheet.
** M85.811 Other specified disorders of bone density and structure, right shoulder
** M85.812 Other specified disorders of bone density and structure, left shoulder
** M85.821 Other specified disorders of bone density and structure, right upper arm
** M85.822 Other specified disorders of bone density and structure, left upper arm
** M85.831 Other specified disorders of bone density and structure, right forearm
** M85.832 Other specified disorders of bone density and structure, left forearm
** M85.841 Other specified disorders of bone density and structure, right hand
** M85.842 Other specified disorders of bone density and structure, left hand
** M85.851 Other specified disorders of bone density and structure, right thigh
** M85.852 Other specified disorders of bone density and structure, left thigh
** M85.861 Other specified disorders of bone density and structure, right lower leg
** M85.862 Other specified disorders of bone density and structure, left lower leg
** M85.871 Other specified disorders of bone density and structure, right ankle and foot
** M85.872 Other specified disorders of bone density and structure, left ankle and foot
** M85.88 Other specified disorders of bone density and structure, other site
** M85.89 Other specified disorders of bone density and structure, multiple sites
Question 1 When will the LCD be updated to either remove Osteopenia as an indication or include the ICD-10 diagnosis codes for Osteopenia?
Answer
• The ICD-10 codes that crosswalk with Osteopenia are under subcategory M85.8 and do not refer to Osteopenia. They are a group of very nonspecific disorders of bone density which do NOT justify or qualify for Vitamin D testing. • The specificity of the ICD-10 testing has refined what disorders qualify for coverage of Oncology Cytogenetics and have allowed us to cull out diagnoses that were previously covered but should not have been. We feel at present the appropriate diagnoses are covered and do not plan on developing a LCD that will expand on the covered ICD-10 codes that CMS has established in NCD 190.3
The following two studies are not covered by Medicare:
78350: Bone density (bone mineral content) study, 1 or more sites; single photon absorptiometry
78351: Bone density (bone mineral content) study, 1 or more sites; dual photon absorptiometry
ICD-10-CM code Z90.721 or Z90.722 should be reported for women s/p oophorectomy.
ICD-10-CM code Z79.51 or Z79.52 should be reported for an individual on glucocorticoid therapy.
ICD-10-CM code Z79.83 should be reported for DXA testing while taking medicines for osteoporosis/osteopenia.
ICD-10-CM Z09 should be reported for an individual who has COMPLETED drug therapy for osteoporosis and is being monitored for response to the therapy.
Medicare covers a bone mass measurement for a beneficiary once every two years (if at least 23 months have passed since the month the last bone measurement was performed). The criteria for bone mass measurement every two years are listed below:
It is performed with a bone densitometer, other than dual photon absorptiometry (DPA) or a bone sonometer (e.g., ultrasound) device that has been approved or cleared for marketing by the Food and Drug Administration (FDA).
It is performed on a qualified individual for the purpose of identifying bone mass, detecting bone loss or determining bone quality. The term “qualified individual” means an individual who meets the medical indications for at least one of the criteria listed below:
o A woman who has been determined by the physician or qualified non-physician treating her to be estrogendeficient and at clinical risk for osteoporosis, based on her medical history and other indicators
o An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral fracture
o An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to 5 mg of Prednisone, or greater, per day for more than 3 months
o An individual with primary hyperparathyroidism
o An individual 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 code 77080 and 77085
The Centers for Medicare & Medicaid Services (CMS) will implement Change Request (CR) 9252 on January 4, 2016, effective October 1, 2015. (See related MLN Matters® article MM9252.) This CR establishes the list of covered conditions and corresponding ICD-10-CM diagnosis codes approved for Bone Mass Measurement studies according to the requirements set forth in National Coverage Determination (NCD) 150.3. CR9252 and accompanying spreadsheet inadvertently omitted the condition of osteopenia and the ICD- 10-CM codes that describe it which are classified to subcategory M85.8- Other specified disorders of bone density and structure. The codes and conditions identified within this subcategory are considered covered indications for bone mass measurement under NCD 150.3 and providers should report these appropriately according to medical documentation.
Additional guidance and education as to the updated complete list of covered indications will be forthcoming as CMS continues to review this issue and the systems updates required. Under ICD-9-CM, the term “Osteopenia” was indexed to ICD-9-CM diagnosis code 733.90 (Disorder of bone and cartilage). This code was listed as a covered condition under the Business requirement 5521.1.1 for CR 5521/NCD 150.3, dated May 11, 2007, when reported with CPT code 77080. (See related MLN Matters article MM552
Under ICD-10-CM, the term “Osteopenia” is indexed to ICD-10-CM subcategory M85.8- Other specified disorders of bone density and structure, within the ICD-10-CM Alphabetic Index. The codes within this subcategory were inadvertently omitted from the CMS spreadsheet that accompanied CR 9252 containing the list of covered conditions and corresponding diagnosis codes. These are considered covered for NCD 150.3 indications.
Below is the list of ICD-10-CM diagnosis codes within subcategory M85.8- that providers may report as covered indications in addition to the current list provided in CR 9252 and its accompanying CMS spreadsheet.
** M85.811 Other specified disorders of bone density and structure, right shoulder
** M85.812 Other specified disorders of bone density and structure, left shoulder
** M85.821 Other specified disorders of bone density and structure, right upper arm
** M85.822 Other specified disorders of bone density and structure, left upper arm
** M85.831 Other specified disorders of bone density and structure, right forearm
** M85.832 Other specified disorders of bone density and structure, left forearm
** M85.841 Other specified disorders of bone density and structure, right hand
** M85.842 Other specified disorders of bone density and structure, left hand
** M85.851 Other specified disorders of bone density and structure, right thigh
** M85.852 Other specified disorders of bone density and structure, left thigh
** M85.861 Other specified disorders of bone density and structure, right lower leg
** M85.862 Other specified disorders of bone density and structure, left lower leg
** M85.871 Other specified disorders of bone density and structure, right ankle and foot
** M85.872 Other specified disorders of bone density and structure, left ankle and foot
** M85.88 Other specified disorders of bone density and structure, other site
** M85.89 Other specified disorders of bone density and structure, multiple sites
Question 1 When will the LCD be updated to either remove Osteopenia as an indication or include the ICD-10 diagnosis codes for Osteopenia?
Answer
• The ICD-10 codes that crosswalk with Osteopenia are under subcategory M85.8 and do not refer to Osteopenia. They are a group of very nonspecific disorders of bone density which do NOT justify or qualify for Vitamin D testing. • The specificity of the ICD-10 testing has refined what disorders qualify for coverage of Oncology Cytogenetics and have allowed us to cull out diagnoses that were previously covered but should not have been. We feel at present the appropriate diagnoses are covered and do not plan on developing a LCD that will expand on the covered ICD-10 codes that CMS has established in NCD 190.3
The following two studies are not covered by Medicare:
78350: Bone density (bone mineral content) study, 1 or more sites; single photon absorptiometry
78351: Bone density (bone mineral content) study, 1 or more sites; dual photon absorptiometry
ICD-10-CM code Z90.721 or Z90.722 should be reported for women s/p oophorectomy.
ICD-10-CM code Z79.51 or Z79.52 should be reported for an individual on glucocorticoid therapy.
ICD-10-CM code Z79.83 should be reported for DXA testing while taking medicines for osteoporosis/osteopenia.
ICD-10-CM Z09 should be reported for an individual who has COMPLETED drug therapy for osteoporosis and is being monitored for response to the therapy.
Medicare covers a bone mass measurement for a beneficiary once every two years (if at least 23 months have passed since the month the last bone measurement was performed). The criteria for bone mass measurement every two years are listed below:
It is performed with a bone densitometer, other than dual photon absorptiometry (DPA) or a bone sonometer (e.g., ultrasound) device that has been approved or cleared for marketing by the Food and Drug Administration (FDA).
It is performed on a qualified individual for the purpose of identifying bone mass, detecting bone loss or determining bone quality. The term “qualified individual” means an individual who meets the medical indications for at least one of the criteria listed below:
o A woman who has been determined by the physician or qualified non-physician treating her to be estrogendeficient and at clinical risk for osteoporosis, based on her medical history and other indicators
o An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral fracture
o An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to 5 mg of Prednisone, or greater, per day for more than 3 months
o An individual with primary hyperparathyroidism
o An individual 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 code 77080 and 77085