Review of Diagnostic Radiology: Bone Mass Measurement Services

Railroad Medicare's Medical Review (MR) unit is conducting reviews of dual-energy X-ray absorptiometry (DXA) bone density study – CPT® Code 77080. Bone mass measurement tests are used to evaluate status of bone disease and also to assess responses to treatment. These tests include the radiological exam and the physician's interpretative report of the scan’s results. Our MR unit selected this code based on internal data analysis indicating risk for over-utilization or claim errors.

Preparing for the Review
As a reminder to providers, regardless of the type of claims selected for review, coverage guidelines require that documentation contain the following:

• The medical record should be complete and legible and include:
  • Beneficiary name
  • Date of service
  • Legible name and signature of the rendering provider, including credentials
• The medical necessity and appropriateness of the services being provided
• That services furnished have been accurately reported
• The place of service
   

Records Under Review Must Contain:
The physician who’s treating the beneficiary is the physician who furnishes the consultation, treats a beneficiary for a specific medical problem, and uses the results in the management of the beneficiary’s specific medical problem. The physician treating the beneficiary must order all diagnostic X-ray tests. Tests not ordered by the physician are considered not reasonable and necessary.

Beneficiaries may qualify for test coverage if they meet one or more of the following criteria:

• Women whose physician or qualified practitioner determines them estrogen-deficient and at clinical osteoporosis risk
• Individuals with vertebral abnormalities
• Individuals getting (or expecting to get) glucocorticoid therapy for more than 3 months
• Individuals with primary hyperparathyroidism
• Individuals monitored to assess FDA-approved osteoporosis drug therapy response

Guidelines state the test frequency should be

• Every 2 years
• More frequently, only with supporting evidence of medical necessity, such as examples listed here:
  • More than three months long-term glucocorticoid therapy
  • In the monitoring of osteoporosis drug therapy

Keep these records available upon request:

• Progress notes or office notes
• Physician order/intent to order
• Test results with the interpretative report supporting DXA bone density study, 1 or more sites; axial skeleton (such as hips, pelvis or spine)
•  Attestation/signature log for illegible signature(s)

Signature Requirements

• Unsigned physician orders or unsigned requisitions alone do not support physician intent to order
• Physicians should sign all orders for diagnostic services to avoid potential denials
• If the signature is missing on a progress note, which supports intent, the ordering physician may complete an attestation statement and submit it with the response
  • If the signature is illegible, an attestation statement or signature log is acceptable
  • Attestation statements are not acceptable for unsigned physician orders/requisitions
     

Conducting the Review
Our MR department will review claims and additional documentation to determine if the services billed were reasonable, necessary and correctly coded, based on Medicare’s coverage and coding guidelines. Remittance advice (RAs) will contain claim determination details. If claims are denied or paid at a lower level of service, notification will be displayed on the RA.  MR will also send a “Claim Review Determination Letter” for each denied claim that explains MR’s findings.

If you disagree with a  claim denial or payment, you can request a first level appeal. Information on this is available on the Appeals page. 

Since these reviews are conducted on both prepayment and postpayment reviews, denials on  claims that were previously paid generally result in an overpayment. Once a provider has notice of an overpayment, a provider may submit an overpayment appeal.

For further assistance, please contact our Provider Contact Center at 888–355–9165. Representatives are available from 8:30 a.m. to 4:30 p.m. in all time zones with the exception of PT, which receives service from 8 a.m. to 4 p.m. PT.

Additional Resources

• National Coverage Determination NCD 150.3 Bone (Mineral) Density Studies
• CMS guidelines for Bone Mass Measurements IOM Publication 100-02; Chapter 15; Section 80.5 (PDF)
• MLN Educational Tool — Medicare Preventive Services
• Bone Density Study Checklist (PDF)