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Professionals Reimbursement Frequently Asked Questions Regarding Bone Density Testing for Medicare Beneficiaries There are five groups of qualified individuals who are now reimbursed by Medicare for bone mass density (BMD) tests: An estrogen deficient woman at clinical risk for osteoporosis An individual with vertebral abnormalities An individual receiving long-term glucocorticoid therapy An individual with primary hyperparathyroidism An individual being monitored to assess the response to or efficacy of a FDA-approved osteoporosis drug therapy. The following section lists questions that are representative of the ones the National Osteoporosis Foundation receives from providers regarding coverage and reimbursement of bone density tests for Medicare beneficiaries:   Q. Are Medicare beneficiaries who are taking estrogen (Estrogen Therapy or Hormone Therapy) eligible for this benefit?     A. The law allows for women who are taking estrogen to still be deemed estrogen deficient by their healthcare professional. Healthcare professionals can decide if their patients are estrogen deficient without having to submit to clinical laboratory tests.     Q. How often can the test be repeated?     A. The BMD test can be repeated every two years, as long as the person falls into one of the above five qualified groups.     Q. If the results of the test are normal or borderline/normal, will providers get reimbursed by Medicare?     A. The results of the BMD test have no bearing on reimbursement. If the person is classified as falling into one of the five "at risk" categories, the test is a covered service.     Q. What ICD-9 code should I use for the first group of qualified individuals?     A. 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 meant as a helpful starting point.  Two new ICD-9 codes are available for use beginning October 1, 2000. These should help alleviate the difficulties some providers have encountered getting BMD tests reimbursed for Medicare beneficiaries who are estrogen deficient and at clinical risk for osteoporosis. The codes are V82.81, which is a special screening code for osteoporosis and V49.81, which is a status code for post-menopausal women. The intent is to use the codes together for this group of qualified individuals. 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 for 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 Health Care Finance Administration to ensure that Medicare carriers are encouraging the use of these codes and reimbursing accordingly.     Q. What are the instances where a follow-up bone mass density test could be done sooner than two years?     A. Two such examples exist. One is if the person has been receiving or is expected to receive steroid therapy that is equivalent to 7.5 mg/day of prednisone or greater for more that three months. A baseline can be performed and then a follow-up test could be done in six months if the health care provider deemed it necessary. After this second test is done, frequency of additional BMD tests would be up to the health care provider and the Medicare carrier and would typically be on a six month or yearly cycle. The second example is when a person is in one of the five qualified groups and a peripheral (heel, wrist or finger measurement) machine is used to do the initial test. If osteoporosis or low bone mass is determined to be present as a result of the test and the health care provider has determined a FDA-approved drug therapy for osteoporosis is indicated, then a second BMD test can be performed sooner that two years if the effectiveness of that therapy will be tested using a different BMD technology, namely DXA (Dual photon X-ray Absorptiometry). The second test is used as a baseline to begin testing every two years to gauge effectiveness of a FDA-approved therapy. Thus, the second BMD test is not to be used to confirm a diagnosis or osteoporosis/low bone mass, but rather as a reference for future tests that monitor effectiveness of the prescribed therapy.     Q. Are all BMD technologies a covered service?     A. The law allows for all FDA-approved BMD technologies to be used to measure bone density if the person falls into one of the five qualified groups.     Q. Can the BMD test be done at a drugstore and be reimbursed by Medicare?     A. A person must be referred by his or her health care provider, confirming that he/she falls into one of the five categories of individuals and therefore is eligible to have the test done. If this is the case, then it is a covered service by Medicare. The results of the test must then be sent to the referring health care provider for follow-up. Top of the page

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