Reimbursement for Patients Covered by Medicare
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| Medicare Coverage of Bone Measurement |
The Bone Mass Measurement Act of 1997 standardizes Medicare coverage
of medically necessary bone mass measurements by providing for uniform
coverage under Medicare Part B. This standardized coverage is effective
for claims with dates of service furnished on or after July 1, 1998.
Measurements must be performed on a qualified individual for the purpose
of identifying bone mass or detecting bone loss or determining bone quality;
and includes a physician's interpretation of the results of the procedure.
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Bone mass measurements are covered for patients with any one of the following indications:
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- A woman who has been determined by the physician
or a qualified nonphysician
practitioner treating her to
be estrogen-deficient and at clinical risk for osteoporosis,
based on her medical history and other findings
- An individual with vertebral abnormalities as demonstrated
by an X-ray indicating
osteoporosis, osteopenia, or vertebral fracture
- An individual receiving (or expecting to receive) corticosteroid
therapy equivalent
to 7.5 mg of prednisone, or greater, per day,
for more than 3 months
- An individual with primary hyperparathyroidism
- An individual being monitored to assess response
to or efficacy of an FDA-approved
osteoporosis drug therapy
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For documentation supporting the medical necessity, physicians and practitioners
may use the ICD-9-CM codes that support medical necessity.
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| Repetitive Testing |
Coverage of follow-up testing is generally limited to one measurement
every two years. More frequent follow-up tests may be permitted when medically necessary.
For example, more frequent testing may be permitted for an individual on long-term
(more than 3 months) steroid therapy.
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| Medicare Reimbursement Rate by State |
The national average payment by Medicare for peripheral ultrasound bone
assessment is approximately $36 per study.
The Medicare reimbursement rate in each state appears in the list below.
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| Denial of Payment |
If the Medicare carrier does not pay for a bone assessment
test that seems to meet the criteria for coverage, the physician's
office can take the following steps:
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1) Assure that the beneficiary is part of one of the five groups of individuals qualified for testing
2) Confirm that the carrier recognizes the ICD-9-CM codes used
3) Send a formal letter with additional information to the carrier to obtain coverage.
Contact Sunlight Medical, Inc. for a form letter.
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Often, there will be instructions regarding next steps
on the denial of coverage as well. The appeals process
should be utilized if an unsatisfactory decision is made
by the local Medicare carrier's office.
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The coding, coverage, and payment information contained herein is gathered
from third party sources and is subject to change. The codes listed are
possible coding options. It is always the provider's responsibility to
determine and submit appropriate codes, charges, and modifiers for the
services that are furnished. Providers should contact their local payers
for specific information on pertinent coding, coverage and payment policies
before a claim is submitted. Sunlight Medical Inc. cannot guarantee success
in obtaining payments for medical services.
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