Diagnosis and procedure coding for bone mass measurement

To provide background information and practical advice about coding for submission of claims for reimbursement for performing bone mass measurement studies.

The current procedural terminology (CPT) codes for diagnoses and procedures related to reduced bone mass and osteoporosis are reviewed, and Medicare and other payer policies are discussed.

Although considerable differences exist in payer policies relative to bone mass measurement, notable consistency is developing for Medicare patients. The CPT codes for pertinent outpatient and inpatient services, and applicable CPT modifiers, are outlined. In addition, examples are provided of criteria imposed for qualification for coverage. If a carrier or payer is not expected to provide coverage for the performance of a bone mass measurement study, an advance beneficiary notice (waiver statement) should be processed and the patient should be informed about the potential responsibility for payment before the test is done.

Osteoporosis is an important and costly disorder that is rapidly increasing in prevalence in our society. Clinical endocrinologists have a critical role in the management of patients with this condition and an opportunity to contribute to high-quality care. Proper selection of patients for assessment and treatment and an understanding of certain restrictions and necessary documentation for insurance coverage may help obtain reimbursement for their care.