Provider Types Affected

Physicians, providers, and suppliers submitting claims to Medicare contractors (carriers, fiscal intermediaries (FI), and/or Part A/B Medicare Administrative Contractors (A/B MAC)) for BMM services provided to Medicare beneficiaries

Provider Action Needed

This article is based on Change Request (CR) 5847 which clarifies the claims processing instructions contained in CR 5521. Only those business requirements changing from CR 5521 are listed in CR 5847, and the BMM benefit policy is not changing. 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.

Background

The Social Security Act (Sections 1861(s)(15) and (rr)(1)) (as added by the Balanced Budget Act of 1997 (BBA; §4106)) standardize Medicare coverage of medically necessary BMMs by providing for uniform coverage under Medicare Part B. Effective for dates of service on and after January 1, 2007, the Calendar Year (CY) 2007 Physician Fee Schedule (PFS) final rule expanded the number of beneficiaries qualifying for BMM by reducing the dosage requirement for glucocorticoid (steroid) therapy from 7.5 mg of prednisone per day to 5.0 mg. It also changed the definition of BMM by removing coverage for a single-photon absorptiometry as it is not considered reasonable and necessary under the Social Security Act (Section 1862 (a)(1)(A)). Finally, it required in the case of monitoring and confirmatory baseline BMMs, that they be performed with a dual-energy x-ray absorptiometry (axial) test.

The Centers for Medicare & Medicaid Services (CMS) issued change request (CR) 5521 (Transmittal 70; May 11, 2007) to provide benefit policy and claims processing instructions for BMM tests. CMS has learned that the updated policy described in CR 5521 is not being implemented uniformly and some covered services are being denied in error.

You can review the MLN Matters article related to CR 5521 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/mm5521.pdf on the CMS Web site. CR 5847 clarifies the claims processing instructions contained in CR 5521 and lists only those business requirements changing from CR 5521. The key clarifications are as follows, effective for dates of services on and after January 1, 2007, the following apply to BMM:

• Certain BMM tests are covered when used to screen patients for osteoporosis subject to the frequency standards described in Section 80.5.5 of the Medicare Benefit Policy Manual, which may be found at http://www.cms.hhs.gov/Manuals/IOM/list.asp on the CMS Web site.
• Medicare contractors will pay claims for screening tests when coded as follows:
• Contains Current Procedural Terminology (CPT) procedure code 77078, 77079, 77080, 77081, 77083, 76977, or G0130; and
• Contains a valid ICD-9-CM 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 ICD-9-CM diagnosis code 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 two-year frequency standards described in 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; and
• Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0 as the ICD-9-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 Medicare 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.

Note: As mentioned, these are clarifications and the BMM benefit policy is not changing. Also, note that while Medicare contractors will not search their files to reprocess claims already processed, they will adjust claims that you bring to their attention.

Additional Information

The official instruction, CR5847, issued to your Medicare carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1416CP.pdf on the CMS Web site.

If you have any questions, please contact your Medicare carrier, FI, or A/B MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer

This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2007 American Medical Association.