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Professionals Reimbursement Reimbursement of Bone Mineral Density Tests The National Osteoporosis Foundation has put together on this site a variety of resources to help answer your questions regarding bone mineral density (BMD) test reimbursement. Please click on any of the headings below to move to that topic/resource. Background Medicare: Conditions for Reimbursement Medicare: Denial of Reimbursement Private Insurers: Denial of Reimbursement ICD-9 Codes Additional Resources View webcast on the impact of DXA Reimbursement cuts Background On July 1, 1998, a Medicare law was implemented allowing coverage of bone density tests for five groups of qualified individuals. These five qualified groups include: an estrogen deficient woman at clinical risk for osteoporosis; an individual with vertebral abnormalities as demonstrated by X-ray to be indicative of osteoporosis, low bone mass or vertebral fracture; an individual receiving long-term glucocorticoid (steroid) therapy; an individual with primary hyperparathyroidism; and an individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy. Top of the page Medicare: Conditions For Reimbursement Certain conditions must be met in order for bone density tests for Medicare beneficiaries to be covered and reimbursed. They include: The beneficiary’s treating qualified health care provider must confirm that the patient falls into one of the five categories of individuals qualified to receive the Medicare benefit (see Background above).   The provider must then order the BMD test based on the fact it is medically necessary. Remember, a test performed without the patient's treating physician ordering the test may result in a repeat test needing to be done. The second test could be denied payment because the first test was already reimbursed. The beneficiary would then have to pay for this second test because Medicare policy generally allows reimbursement for the test every two years. Medicare allows for a follow-up BMD test sooner than two years under certain circumstances. Treating physicians/practitioners many times prefer to specify where they send their patients for tests because they can monitor the quality of the testing facility to be sure high medical standards of test quality are followed.   The test must be appropriately supervised by a physician.   The person operating the BMD machine must be appropriately licensed by the State in which the test is done.   A physician/practitioner order can not be requested after the test is performed. The treating practitioner must order the test in advance.   If an independent testing enterprise is in business solely to supply tests, no practitioner with financial ownership in this enterprise may order the test, with certain limited exceptions. (For exceptions, see Medicare physician self-referral law at http://www.cms.hhs.gov/PhysicianSelfReferral/)   Some carriers will require the people responsible for performing the BMD test to have a written practitioner order for the test before the test is performed, and will do an audit to assure this requirement is met. The results of the test must then be sent to the referring practitioner for follow-up. If any of these requirements are not met, the claim is subject to denial of payment and perhaps even repayment. If the beneficiary is directly reimbursed, and these criteria are not met, he/she may also be asked to refund payment. Top of the page Medicare: Denial of Reimbursement If the Medicare carrier does not pay for a bone density test that seems to meet the criteria for coverage, the physician/practitioner can look up the Medicare carrier's review policy which can be accessed via the web. Medicare carrier information like names, addresses and so forth, are also available on this site. The physician/practitioner should also collect the following information: Written documentation outlining why a bone density test was recommended. Which of the five qualified groups of individuals applies to the beneficiary. The ICD-9 codes that were used for the claim. A copy of the letter indicating why the Medicare carrier denied coverage for the bone density test. This documentation should be sent to the local Medicare carrier's office with a cover letter indicating why this coverage decision is not in the best interest of the beneficiary. If there is no web access, the blue pages in the phone book can provide direction under United States Government; Health and Human Services, Department of; Centers for Medicare and Medicaid Services. Often, there will be instructions regarding next steps with the denial of coverage as well. The appeals process should be utilized if there is not a satisfactory decision made by the local Medicare carrier's office. Additional information on the appeals process can be found at http://www.cms.hhs.gov under Professionals/Medicare Health Plans/Appeals and Grievances. Regional CMS offices can be found on the web at http://www.cms.hhs.gov. On the left-hand side of the web page, select Resources/Contacts. Under Type of Organization, choose CMS RO for CMS Regional Offices and choose the appropriate state. The Medicare Coverage Advisory Committees (MCAC's) can also be contacted. The purpose of the MCAC's is to advise CMS on whether specific medical items and services are reasonable and necessary under Medicare law. If the local policy is in conflict with national policy, the MCAC may be able to assist. Information about the MCAC's can be found by going to www.cms.hhs.gov. On the left-hand side of the web page, choose Topics/Coverage. Then on the right-hand side of the page under Topics, choose MCAC. Additional information about upcoming MCAC meetings, etc. can be found by selecting Executive Secretary. Coverage Personnel Directory can also be found by going to www.cms.hhs.gov. Select Topics/Coverage on the left-hand side of the web page. On the right-hand side of the page then choose Topics/Directory. Top of the page Private Insurers: Denial of Reimbursement Reimbursement amounts and coverage criteria for bone density tests performed on people covered with private insurance through employers are variable. There is currently no federal law similar to Medicare that standardizes coverage criteria and reimbursement rates for bone density tests on the private side. Furthermore, the Employee Retirement Income Security Act (ERISA) preempts any state consumer rights laws and bone mass measurement legislation on the state level in most cases. If there is disagreement about reimbursement or coverage criteria, the appeal/grievance process offered through health plans is one option for providers and consumers. The Medical Director of the health plan can also be contacted once appropriate documentation is in place. Documentation could include such items as why the provider believes a bone density test is necessary, when the test was done, ICD-9 codes used and an explanation of why coverage was denied. Another option is to contact your state's insurance commissioner with the appropriate documentation to discuss denial of care. A list of commissioners can be found at the website of the National Association of Insurance Commissioners: www.naic.org/1regulator/ under State Insurance Department Health Contacts or under the Map of Insurance Regulators. Administrators also can be contacted to ask that bone density testing be added as a benefit for at-risk individuals through an employer. One health insurance plan can offer many different benefit packages to a variety of employers based on the criteria the employer is using to select a plan for employees. Individuals and providers can also write their state and federal legislators about their issue. Please include appropriate documentation. Top of the page ICD-9 Codes Beginning October 1, 2000 new ICD-9 codes became available for use that should help alleviate the difficulties some providers have encountered getting BMD tests reimbursed. These codes are for Medicare beneficiaries who are estrogen deficient and at clinical risk for osteoporosis. The first, V82.81, is a special screening code for osteoporosis. This is to be used when the treating, qualified provider deems a bone density test medically necessary. An additional status code is then necessary to use in conjunction with V82.81 to further identify the appropriate group of qualified Medicare beneficiaries. The two choices are now V49.81 [postmenopausal (natural) status] and V07.4 (postmenopausal hormone replacement therapy status). The National Osteoporosis Foundation worked with the ICD-9 Coordination and Maintenance Committee to help develop these new codes to help ease the coding confusion of this qualified group. Please note that although these new codes are available for use, your local Medicare carrier may not recognize them. Therefore, use of the new codes does not guarantee reimbursement. NOF will be working with the Centers for Medicare and Medicaid Services to ensure that Medicare carriers are encouraging the use of these codes and reimbursing accordingly. Up to this point, no ICD-9 code or codes have perfectly captured this first group of qualified individuals. Many providers to date have been using for example, 256.2 (postablative ovarian failure), 256.3 (other ovarian failure), 627.2 (menopausal or female climacteric states e.g. flushing and headache associated with menopause), and 259.9 (unspecified endocrine disorder). These four codes are not all-inclusive and listing them is intended for informational purposes only. Top of the page Additional Resources NOF's Medicare Flyers briefly explain the circumstances under which Medicare will cover bone density tests. Order Medicare Flyers: Enrollee to share with patients or Medicare Flyers - Provider to share with colleagues. Frequently Asked Questions (FAQs) about bone density tests for Medicare beneficiaries. Contact other Professional Medical Societies and their contact person for reimbursement issues. (IE: AAOS, AAPMR, AACE, ACOG, ACR, AGS, AMA, and the Endocrine Society.) Manufacturers of Bone Densitometry Equipment may be able to assist with reimbursement questions regarding their specific machines. The Medicare Rights Center (MRC) is a national, not-for-profit organization that helps ensure that older adults and people with disabilities get good affordable health care. MRC provides telephone hotline services to individuals who need answers to Medicare questions or help securing coverage and getting the health care they need. Visit http://www.medicarerights.org/ for more information. For advice on insurance matters for both consumers and health care providers, contact your state’s Information, Counseling and Assistance Grants -- Project Directors. A directory of Project Directors is kept by the State Health Insurance Information, Counseling and Assistance (SHIP) Resource Center. For this list, contact: SHIP Resource Center, National Association of State Units on Aging, 1225 I Street, NW #725, Washington, DC 20005; phone: (202) 898-2578. A copy of the Project Directors directory is available upon request. Denial of care can be discussed with your state’s insurance commissioner. A list of commissioners can be found at the website of the National Association of Insurance Commissioners: http://www.naic.org/1regulator/ under Regulator’s Name and Address. The Federal Register issue that outlines the intent of the Medicare law with respect to the five groups of qualified individuals eligible for a bone density test: http://www.access.gpo.gov/su_docs/fedreg/a980624c.html and by scrolling down to Health Care Financing Administration (Federal Register, June 24, 1998, Volume 63, Number 1211, Page 34320-34328). The Federal Register issue that includes changes to the ICD-9 Coding System: http://www.access.gpo.gov/su_docs/fedreg/a000505c.html and by scrolling down to Health Care Financing Administration; pages 26293 and 2683 deal with the two new osteoporosis codes (Federal Register, May 5, 2000, Volume 65, Number 88, Page 34320-34328). Although not directly related to bone density tests, a number of callers request information about Drug Assistance Programs. The Pharmaceutical Research and Manufacturers of America (PhRMA) publishes a guide that lists drug companies with assistance programs for those people who qualify. PhARMA can be reached at 202-835-3400, or the guide can be found on-line at http://www.phrma.org/searchcures/dpdpap/ under Directory of Prescription Drug Patient Assistance Programs. If the information you need to answer your reimbursement question is not found here, please contact the Public Policy Department of NOF with your query. The Public Policy department can be reached at 202-223-2226. Top of the page

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