Bone Mass Measurements - JE Part B
Bone Mass Measurements
"Bone mass measurement," also known as "bone density study," is a radiological or radioisotope procedure or other procedure approved by the Food and Drug Administration (FDA). It identifies bone mass, detects bone loss, or determines bone quality. Bone mass measurements evaluate bone disease and/or responses of treatment; they include a physician's interpretation of the procedure's results. The studies assess bone mass or density associated with osteoporosis and other bone abnormalities.
Bone density is usually studied using diagnostic bone mass measurement techniques recognized by the FDA. Bone density can be measured at the wrist, spine, hip, or calcaneus (heel). Single and combined measurements may be required to diagnose bone disease, monitor bone changes with disease progression, or monitor bone changes with therapy.
Medicare provides coverage for the following densitometers:
- A stationary device permanently located in an office,
- A mobile device transported by vehicle from site to site, and
- A portable device picked up and moved from one site to another.
Medicare's bone mass measurement benefit includes a physician's interpretation of the procedure's results.Medicare provides coverage of bone mass measurements that meet coverage criteria 1-6 below:
- The bone mass measurement is performed on a qualified individual. A "qualified individual" means a Medicare beneficiary who meets the medical indications for at least one of the following categories:
- A woman who has been determined by the physician or qualified non-physician practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings.
- An individual with vertebral abnormalities, as demonstrated by an X-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral fracture.
- An individual 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.
- An individual with known primary hyperparathyroidism; or
- An individual being monitored to assess the response to, or efficacy of, an FDA-approved osteoporosis drug therapy.
- The physician or qualified non-physician practitioner treating the qualified individual must provide an order for a bone mass measurement test, following an evaluation of the need for a bone mass measurement that included a determination of the medically appropriate measurement for the individual.
- The service must be a radiologic or radioisotopic procedure (or other procedure) meets the following requirements:
- Is performed with a bone densitometer (other than dual photon absorptiometry) or a bone sonometer (e.g., ultrasound) device approved or cleared for marketing by the FDA;
- Is performed for the purpose of identifying bone mass, detecting bone loss, or determining bone quality; and
- Includes a physician's interpretation of the procedure's results.
- A qualified supplier or provider must furnish such services under the appropriate level of supervision by a physician.
- The service must be reasonable and medically necessary to diagnose, treat, or monitor a qualified individual.
- The service must be performed at a frequency that conforms to the Frequency Requirements section.
Medicare provides coverage of a bone mass measurement that meets the criteria described above once every 2 years (i.e., at least 23 months after the last covered bone mass measurement was performed).
- CMS Change Request (CR) 9252 - ICD-10 Conversion/Coding Infrastructure Revisions to National Coverage Determinations (NCDs) - 3rd Maintenance CR