Payment Methodology and HCPCS Coding

140.1 - Payment Methodology and HCPCS Coding (Rev. 4150, Issued: 10-26-2018, Effective: 04-01-19, Implementation: 04-01-19) A/B MACs (B) pay for BMM procedures based on the Medicare physician fee schedule. Claims from physicians, other practitioners, or suppliers where assignment was not taken are subject to the Medicare limiting charge. The A/B MACs (A) pay for BMM procedures under the current payment methodologies for radiology services according to the type of provider. Do not pay BMM procedure claims for dual photon absorptiometry, CPT procedure code 78351. Deductible and coinsurance do not apply. Any of the following CPT procedure codes may be used when billing for BMMs through December 31, 2006. All of these codes are bone densitometry measurements except code 76977, which is bone sonometry measurements. CPT procedure codes are applicable to billing A/B MACs (A and B). 76070 76071 76075 76076 76078 76977 78350 G0130 Effective for dates of services on and after January 1, 2007, the following changes apply to BMM: New 2007 CPT bone mass procedure codes have been assigned for BMM. The following codes will replace current codes, however the CPT descriptors for the services remain the same: 77078 replaces 76070 77079 replaces 76071 77080 replaces 76075 77081 replaces 76076 77083 replaces 76078 Effective for dates of service on and after January 1, 2015, contractors shall pay for bone mass procedure code 77085 (Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites, axial skeleton, (e.g., hips, pelvis, spine), including vertebral fracture assessment.) Certain BMM tests are covered when used to screen patients for osteoporosis subject to the frequency standards described in chapter 15, section 80.5.5 of the Medicare Benefit Policy Manual. Contractors will pay claims for screening tests when coded as follows: Contains CPT procedure code 77078, 77079, 77080, 77081, 77083, 76977 or G0130, and Contains a valid diagnosis code indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy. Contractors are to maintain local lists of valid codes for the benefit’s screening categories. Contractors will deny claims for screening tests when coded as follows: Contains CPT procedure code 77078, 77079, 77081, 77083, 76977 or G0130, but Does not contain a valid diagnosis code from the local lists of valid diagnosis codes maintained by the contractor for the benefit’s screening categories indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy. Dual-energy x-ray absorptiometry (axial) tests are covered when used to monitor FDA- approved osteoporosis drug therapy subject to the 2-year frequency standards described in chapter 15, section 80.5.5 of the Medicare Benefit Policy Manual. Contractors will pay claims for monitoring tests when coded as follows: Contains CPT procedure code 77080 or 77085, and Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0 as the ICD-9-CM diagnosis code or M81.0, M81.8, M81.6 or M94.9 as the ICD-10-CM diagnosis code. Contractors will deny claims for monitoring tests when coded as follows: Contains CPT procedure code 77078, 77079, 77081, 77083, 76977 or G0130, and Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0 as the ICD-9-CM diagnosis code, but Does not contain a valid ICD-9-CM diagnosis code from the local lists of valid ICD-9-CM diagnosis codes maintained by the contractor for the benefit’s screening categories indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy. Does not contain a valid ICD-10-CM diagnosis code from the local lists of valid ICD-10-CM diagnosis codes maintained by the contractor for the benefit’s screening categories indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy. Single photon absorptiometry tests are not covered. Contractors will deny CPT procedure code 78350. The A/B MACs (A) are billed using the ASC X12 837 institutional claim format or hardcopy Form CMS-1450. The appropriate bill types are: 12X, 13X, 22X, 23X, 34X, 71X (Provider-based and independent), 72X, 77X (Provider-based and freestanding), 83X, and 85X. Effective April 1, 2006, type of bill 14X is for non-patient laboratory specimens and is no longer applicable for bone mass measurements. Information regarding the claim form locators that correspond to the HCPCS/CPT code or Type of Bill are found in chapter 25. Providers must report HCPCS codes for bone mass measurements under revenue code 320 with number of units and line item dates of service per revenue code line for each bone mass measurement reported. A/B MACs (B) are billed for bone mass measurement procedures using the ASC X12 837 professional claim format or hardcopy Form CMS-1500.