Clinical Policy Title: Bone mineral density (BMD) … · bone mineral density 2.5 standard deviations (-2.5 T-score) below the mean found in young, healthy adults. Bone mass measurements

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Clinical Policy Title: Bone mineral density (BMD) measurement

Clinical Policy Number: 17.01.01

Effective Date: September 1, 2013

Initial Review Date: April 23, 2013

Most Recent Review Date: April 27, 2016

Next Review Date: April 2017

Related policies:

None.

ABOUT THIS POLICY: AmeriHealth Caritas Pennsylvania has developed clinical policies to assist with making coverage determinations.

AmeriHealth Caritas Pennsylvania’s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by AmeriHealth Caritas Pennsylvania when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas Pennsylvania’s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas Pennsylvania’s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas Pennsylvania will update its clinical policies as necessary. AmeriHealth Caritas Pennsylvania’s clinical policies are not guarantees of payment.

Coverage policy

AmeriHealth Caritas Pennsylvania considers the use of bone mineral density (BMD) measurement using

dual-energy X-ray absorptiometry (DXA/DEXA ) to be clinically proven and, therefore, medically

necessary for members when at least one of the following clinical criteria and one of the following

equipment criteria are met:

Clinical criteria — At least one of the following clinical conditions:

For women age 65 and older.

For men age 70 and older.

For men or women with a fracture after age 50.

For postmenopausal women younger than age 65, and/or men ages 50–69, based on a personal or familial risk factor

that includes, but is not limited to, at least one of the following:

A family history of a first-degree relative with osteoporosis or fracture.

An individual low body mass index (BMI) and/or low weight (BMI of less than 21 kg per m2, and/or body weight

of 127 pounds or less).

Policy contains:

Bone mineral density (BMD)

measurement.

Dual-energy X-ray

absorptiometry (DEXA or

DXA).

Osteoporosis

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A 10-year major osteoporosis-related U.S.-adjusted FRAX® probability of greater than or equal to 9.3 percent.

A personal history of at least one of the following:

Prior history of low-trauma or vertebral fracture.

Poor nutrition with low levels of calcium or vitamin D intake.

Excessive alcohol intake (more than 14 units/week for women; more than 21 units/week for men).

An increased likelihood of falls (may be associated with neurological disorders, pharmaceutical therapy).

Low levels of physical activity.

Current exposure to cigarettes (smoking).

Intake of medications that cause hypogonadism (e.g., androgen deprivation therapy).

Hemochromatosis.

Homocystinuria.

Hypophosphatasia.

Multiple myeloma.

Thalassemia.

Thyrotoxicosis.

A woman currently going through menopause with an associated increased risk factor for fractures, such as current

intake of high-risk medication, low body weight and history of low-trauma fracture.

Postmenopausal women after ending estrogen therapy.

Postmenopausal women under age 65 with at least one of the following criteria:

Asian (nonblack) or Caucasian race.

Late menarche and early menopause.

A woman of any age with exercise-induced amenorrhea or oligomenorrhea.

An individual of any age with documented vertebral abnormalities indicating osteopenia, osteoporosis or vertebral

fracture as evidenced by X-ray studies.

Individuals with a history of bariatric surgery.

Individuals with primary hyperparathyroidism.

Individuals of any age under current or anticipated pharmaceutical management associated with the development of

low bone mass or bone loss, including but not limited to:

Glucocorticoid therapy, equivalent to at least 5 mg per day or greater of prednisone for more than a continuous

three-month period.

A condition associated with a predisposition to bone loss or low bone mass.

Other medications known to adversely affect bone mass, such as aromatase inhibitors and anti-seizure drugs.

Individuals of any age with a documented disorder actively associated with osteoporosis, including but not limited to

the following:

Cystic fibrosis.

Osteogenesis imperfecta.

Rheumatoid arthritis.

Type 1 insulin-dependent diabetes.

Longstanding and untreated chronic liver disease, chronic malabsorption or malnutrition.

In certain indications, AmeriHealth Caritas Pennsylvania considers BMD testing medically necessary and indicated more than

once every 23 months, when at least 11 months have elapsed since the previous BMD measurement and testing is limited to

the following:

An individual currently receiving pharmaceutical management with a glucocorticoid (steroid) equivalent to an average

of 5.0 mg of prednisone or greater per day for more than 3 months.

Confirming baseline BMDs to permit monitoring of members when the initial BMD was not done on the axial skeleton

using a DXA/DEXA system. An individual being monitored to assess the response to, or efficacy of, a U.S. Food and

Drug Administration (FDA)-approved osteoporosis drug therapy when performed with a DXA/DEXA system (axial

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skeleton) until, over time, a response to such therapy has been documented.

AND

Tests performed on equipment meeting one of the following criteria:

An AmeriHealth Caritas Pennsylvania-approved and FDA-approved densitometer is used when the

results of the BMD study will be used in treatment decisions.

A peripheral BMD may be considered to be proven and medically necessary when an FDA-approved

densitometer is used for either of the following:

An individual physically unable to undergo axial skeleton (hip/spine) measurements due to physical

size and surpassing the table limits for the DXA/DEXA device.

Individuals diagnosed with hyperparathyroidism for whom a BMD of the forearm is crucial to

diagnosis.

All other uses of BMD testing not described within the context of this policy are considered to be

unproven and not medically necessary, as their effectiveness is not supported by peer-reviewed

professional literature.

Limitations:

AmeriHealth Caritas Pennsylvania considers the following to be limitations to this policy:

DXA/DEXA should not be performed if contractures prevent the safe and appropriate

positioning of the individual, especially in pediatric cases (ISCD 2007).

The minimum time interval for repeating a bone density measurement to monitor

treatment with a bone-active agent or disease process is six months for pediatric cases (ISCD

2007).

Only dual-energy X-ray absorptiometry (DXA/DEXA, 77080) is used to monitor osteoporosis

drug therapy.

BMD measurement must include physician interpretation.

BMD measurement is a service limited to once every two years (at least 23 months elapsing

since the last body mass measurement [BMM] was performed).

Repeat BMD testing at intervals of less than one year may have untoward effects on

reliability when applied to treatment decisions, as the margin of error for the test is usually

greater than the interval treatment effect on BMD.

Variability of test-to-test results, even with the use of the same testing device, should be

considered when addressing the expected effects of treatment.

Performing both a peripheral and an axial BMD test on the same day is considered not

medically necessary.

BMD testing should be performed at DXA/DEXA facilities using accepted quality assurance

measures.

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AmeriHealth Caritas Pennsylvania considers the following BMD tests not reasonable and medically

necessary, as the use of these tests is not supported by peer-reviewed professional literature:

Single-photon absorptiometry (CT code 78350).

Dual-photon absorptiometry (CPT 78351).

All other uses of BMD measurement are not medically necessary.

Note: The following CPT/HCPCS codes are not listed in the Pennsylvania Medicaid fee schedule:

77085 -Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g.,

hips, pelvis, spine), including vertebral fracture assessment

77086 - Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA)

Alternative covered services:

Physician office visits and evaluations.

Background

Bone strength is an important factor in an individual’s overall mobility and resistance to fractures and is

determined in part by bone density. Bone strength and density are determined by the mineral content

of a specified area as applied to size and shape (mass) of a bone. Low-density bones are less healthy,

more fragile and prone to fractures. Osteoporosis is a disease marked by the progressive decrease in

bone density, increased fragility and a susceptibility to bone fractures. Osteoporosis-related changes

occur when bone loss exceeds bone formation. Osteoporotic changes in the bones are commonly found

in postmenopausal women; however, they are seen in both genders and all people of advancing age.

Secondary osteoporosis may be caused by conditions that impair the intake and utilization of nutrients,

such as anorexia nervosa, bariatric surgery or prolonged steroid drug treatment.

The United States Preventative Services Task Force (USPSTF) recommendations for BMD testing include

all racial and ethnic groups for women age 65 and older, as the consequences of failing to identify and

treat women with low BMD are significant. The same recommendations do not define an upper age limit

for screening women because of the increased risk for fractures with the advancement in age and the

fact that treatment harms remain small. These same guidelines recommend women under age 65 who

have a fracture risk greater than or equal to that of a 65-year-old white woman also be screened for

BMD (USPSTF 2011). The American College of Physicians states that high-quality evidence shows that

age, low body weight, physical inactivity and weight loss are strong predictors of an increased risk for

osteoporosis in men (ACOP 2008).

The National Osteoporosis Foundation (NOF) 2013 recommendations include both men and women.

The NOF agrees with the USPSTF recommendation that women age 65 and older should be screened,

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and adds recommendations that men age 70 and older be tested regardless of risk factors. The NOF

further provides indications for bone mineral testing for men between the ages of 50 and 69. The 2013

updated NOF Clinician’s Guide stresses the importance of screening vertebral imaging to diagnose

asymptomatic vertebral fractures; provide updated information on calcium, vitamin D and osteoporosis

medications; and address treatment durations.

Various clinical and special interest organizations have published clinical guidelines for osteoporosis and

BMD testing. However, at the writing of this policy, no single unifying consensus statement has been

formulated. All professional societies acknowledge the aging of the U.S. population will likely lead to an

increase in cases of osteoporosis. BMD testing could detect osteoporosis in a large portion of the

population and may prevent many fractures and fracture-related illnesses in this population.

Osteoporosis is diagnosed by using the globally accepted World Health Organization (WHO) definition of

BMD measurement and fracture risk assessment. The WHO definition of osteoporosis is based on a

bone mineral density 2.5 standard deviations (-2.5 T-score) below the mean found in young, healthy

adults. Bone mass measurements are performed to identify bone mass (mineral density), detect bone

loss or determine bone quality. The WHO has developed the fracture risk assessment (FRAX®), a tool

used to combine the risks associated with a femoral neck BMD and other clinical risk factors for an

evaluation of an individual’s overall fracture risk. This computer-based tool, available on the WHO

website, also has several simplified paper versions. Access to the Web-based tool enables calculations

for the major races found on each continent. FRAX® algorithms are used to assess an individual’s 10-

year fracture probability for both femoral and other major osteoporotic fractures (clinical spine,

forearm, hip or shoulder fracture).

Skeletal health in children between the ages of 5 and 19 is assessed by the use of fracture prediction and

definition of osteoporosis. Fracture prediction is the identification of significant fractures of the long

bones, vertebral compression fractures, or two or more long bone fractures of the upper body. A

diagnosis of osteoporosis in children is not made solely on the basis of densitometric criteria. The

diagnosis must take into account the clinically significant fracture history and BMD or low bone mineral

content (BMC). Low BMD or BMC is defined by the presence of a BMC or BMD Z-score less than or equal

to -2.0, adjusted for the child’s gender, age and body size (ISCD 2007).

BMD tests are noninvasive, used to identify individuals with osteoporosis and may be used to monitor

response to osteoporosis treatments. The goal of detecting a low BMD in an individual is to assist with

the decision-making toward treatment to prevent a fragility (osteoporotic) fracture. The risk-predicting

ability of BMD studies has been compared to the use of cholesterol testing to predict hypertension and

heart disease. BMD studies are radiologic or radioisotopic and are performed with an FDA-approved

bone densitometer (other than single-photon or dual-photon absorptiometry) or a bone sonometer

system. The gold standard and most widely used method for BMD is DXA/DEXA).

DEXA requires a short scan time and is used to provide extremely precise and reproducible BMD

measurement. The preferred DEXA measurement sites are located on the central skeleton; these are the

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total hip, femoral neck, total lumbar spine or some combination of these sites. Central skeletal sites are

preferred for baseline and serial BMD measurements and are also more likely than peripheral skeletal

sites to show a response to treatment. Examples of peripheral skeletal sites are the wrist, finger,

forearm or heel. Peripheral testing only uses one site, and this may be problematic because of

differences in bone density between different skeletal sites. Low bone densities in other skeletal areas

may be overlooked. It is important to note that the diagnostic criteria established by the WHO and

recommendations by the American Association of Clinical Endocrinologists (AACE) apply only to the

peripheral radius site and central (total hip, femoral neck, lumbar spine) site DXA measurements (AACE,

2010).

Other BMD techniques use both the central and skeletal sites. In addition to DEXA, the established

methods for BMD testing are the following:

Quantitative computed tomography (QCT).

Radiographic absorptiometry (RA; photodensitometry).

Single-energy X-ray absorptiometry (SEXA).

Ultrasound BMD studies (i.e., bone sonometry).

QCT is a three-dimensional BMD test that also uses both central and peripheral skeletal sites. The

measurement is calculated using the differential absorption of ionizing radiation by calcified (bone)

tissue. QCT is the only technique that can distinguish between cortical and cancellous bone and may use

standard CT scanners. However, it is expensive, is not widely available and uses a relatively high amount

of radiation exposure. RA uses plain radiographs of peripheral sites, most commonly from the hand or

heel. Its use decreased as other precise nonradiographic techniques became available. Single-photon

absorptiometry (SPA) uses a single-energy beam usually passed through the wrist to provide a

quantitative measurement of bone mineral and trabecular bone. Dual-photon absorptiometry measures

BMD by the absorption of a dichromatic beam by bone material, and has limited usefulness in

monitoring BMD changes. In current practice, these methods are rarely used. In particular, dual-photon

absorptiometry may be considered obsolete.

Searches

AmeriHealth Caritas Pennsylvania searched PubMed and the databases of:

UK National Health Services Centre for Reviews and Dissemination.

Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other

evidence-based practice centers.

The Centers for Medicare & Medicaid Services (CMS).

We conducted searches on March 23, 2016. Search terms were “bone measurement” and

“osteoporosis,” “menopause” and “DEXA (MeSH).”

We included:

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Systematic reviews, which pool results from multiple studies to achieve larger sample sizes

and greater precision of effect estimation than in smaller primary studies. Systematic

reviews use predetermined transparent methods to minimize bias, effectively treating the

review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies.

Guidelines based on systematic reviews.

Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple

cost studies), reporting both costs and outcomes — sometimes referred to as efficiency

studies — which also rank near the top of evidence hierarchies.

Findings

Studies and national guidelines recommend screening for osteoporosis in women age 65 or older and in

younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman with

no additional risks. The studies may be performed using either single-photon or dual-photon

absorptiometry. The frequency of examinations more often than every 23 months has not been

demonstrated to improve outcomes.

Policy updates:

No change in coverage.

Summary of clinical evidence:

Citation Content, Methods, Recommendations

Erlichman and Holohan

(1996)

Yearly density

measurements

Key points:

Explained it is unlikely yearly densitometry would be clinically indicated given the

fact that 1% precision error is rarely attained and that a 3% annual loss in bone

mass would be distinctly uncommon.

Precision errors in the range of 2% to 3% and annual bone mass losses of 1% to

2% are parameters more representative of published data.

In those instances, the minimum interval between densitometry measures

necessary to document bone mass loss would be between 3.7 and 6 years.

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Qaseem et al. (2008)

A clinical practice guideline

on osteoporosis in men

issued by the American

College of Physicians

(ACP)

Key points:

Recommended physicians periodically assess elderly men for risk factors for

osteoporosis. Although osteoporosis is often viewed as a disease of women,

studies show osteoporotic fractures in men are associated with significant

morbidity and mortality, resulting in substantial disease burden, death and health

care costs.

The prevalence of osteoporosis is estimated to be 7% in white men, 5% in black

men and 3% in Hispanic men. Data on prevalence of osteoporosis in Asian-

American men and other ethnic groups is lacking.

The guideline recommended that clinicians assess risk factors for osteoporosis in

older men and obtain a DXA scan for men at increased risk for osteoporosis who

are candidates for drug therapy.

Risk factors for osteoporosis in men include age greater than 70; low body weight

(body mass index [BMI] less than 20 to 25 kg/m2); weight loss (greater than 10%);

lack of regular physical activity such as walking, climbing stairs, carrying weights,

housework or gardening; use of oral corticosteroids; previous osteoporotic fracture;

and androgen deprivation therapy.

ACP also recommended further research to evaluate osteoporosis screening tests

in men and that, presently, non-DXA tests are either "too insensitive or have

insufficient data to reach conclusions.”

USPSTF (2011)

The U.S. Preventive

Services Task Force

updated its 2002

recommendation on

screening for osteoporosis.

Key points:

The USPSTF evaluated evidence on the diagnostic accuracy of risk assessment

instruments for osteoporosis and fractures, the performance of DEXA and

peripheral bone measurement tests in predicting fractures, the harms of screening

for osteoporosis, and the benefits and harms of drug therapy for osteoporosis in

women and men.

The USPSTF recommends screening for osteoporosis in women age 65 older and

in younger women whose fracture risk is equal to or greater than that of a 65-year-

old white woman who has no additional risk factors (Grade B recommendation).

The USPSTF concluded the current evidence is insufficient to assess the balance

of benefits and harms of screening for osteoporosis in men.

Glossary

Bone density or bone mineral density (BMD) — The amount of bone mineral in bone tissue. The

concept is f mass of mineral per volume of bone (relating to density in the physics sense), although

clinically it is measured by proxy according to optical density per square centimeter of bone surface

upon imaging.

Dual-energy X-ray absorptiometry (DXA, previously DEXA[1][2]) — A means of measuring bone mineral

density (BMD). Two X-ray beams, with different energy levels, are aimed at the patient's bones. When

soft tissue absorption is subtracted out, the BMD can be determined from the absorption of each beam

https://en.wikipedia.org/wiki/Bone_mineral

https://en.wikipedia.org/wiki/Bone_tissue

https://en.wikipedia.org/wiki/Concept

https://en.wikipedia.org/wiki/Mass

https://en.wikipedia.org/wiki/Volume

https://en.wikipedia.org/wiki/Density

https://en.wikipedia.org/wiki/Physics

https://en.wikipedia.org/wiki/Medicine#Clinical_practice

https://en.wikipedia.org/wiki/Optical_density

https://en.wikipedia.org/wiki/Bone

https://en.wikipedia.org/wiki/Medical_imaging

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by bone. Dual-energy X-ray absorptiometry is the most widely used and most thoroughly studied bone

density measurement technology.

Fracture risk assessment (FRAX®) — A tool developed by the World Health Organization Collaborating

Centre for Metabolic Bone Diseases to evaluate the fracture risk of patients.

Low trauma fracture — A fracture incurred from a lesser amount of force. An example is fracturing a

limb when falling from a standing position.

Osteoporosis — A disorder of the skeleton that lowers bone strength and may cause an increased risk of

a bone fracture.

References

Professional society guidelines/other:

American Association of Clinical Endocrinologists (AACE) Osteoporosis Task Force. AACE Medical

Guidelines for Clinical Practice for the diagnosis and treatment of postmenopausal osteoporosis. Endocr

Pract. 2010;16(3): 1 – 37. Also available on the AACE website at https://www.aace.com/files/osteo-

guidelines-2010.pdf. Accessed March 23, 2016.

American College of Obstetricians and Gynecologists (ACOG). Osteoporosis Guidelines. August 21, 2012.

[ACOG website.] Available at

http://www.acog.org/About%20ACOG/News%20Room/News%20Releases/2012/Osteoporosis%20Guid

elines%20Issued.aspx. Accessed March 23, 2016.

American College of Radiology (ACR). ACR-SSR Practice Guidelines for the performance of Dual-Energy X-

ray Absorptiometry (DXA). Revised 2008. [ACR website.] Available at

http://www.acr.org/~/media/EB34DA2F786D4F8E96A70B75EE035992.pdf. Accessed March 23, 2016.

American College of Radiology (ACR). ACR Appropriateness criteria for Osteoporosis and Bone Mineral

Density. Original 1998. Amended 2014. [ACR website.]

http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/OsteoporosisAndBoneMineralDe

nsity.pdf. Accessed March 23, 2016.

The Institute for Clinical Systems Improvement (ICSI). Diagnosis and treatment of osteoporosis.

Bloomington (MN): Institute for Clinical Systems Improvement (ICSI). Revised 2016. www.guideline.gov/.

March 23, 2016.

International Society for Clinical Densitometry (ISCD). Official Positions 2007. Adult,. [ISCD website.]

October 2007. Available at http://www.iscd.org/official-positions/2007-iscd-official-positions-adult/.

Accessed March 23, 2016.

http://www.acog.org/About%20ACOG/News%20Room/News%20Releases/2012/Osteoporosis%20Guidelines%20Issued.aspx

http://www.acog.org/About%20ACOG/News%20Room/News%20Releases/2012/Osteoporosis%20Guidelines%20Issued.aspx

http://www.acr.org/~/media/EB34DA2F786D4F8E96A70B75EE035992.pdf

http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/OsteoporosisAndBoneMineralDensity.pdf

http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/OsteoporosisAndBoneMineralDensity.pdf

http://www.guideline.gov/

http://www.iscd.org/official-positions/2007-iscd-official-positions-adult/

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National Osteoporosis Foundation (NOF). Clinicians guide to prevention and treatment of osteoporosis.

[NOF website.] Original 2008. Revised January 2013. Available at

http://www.nof.org/files/nof/public/content/file/950/upload/523.pdf. Accessed March 23, 2016.

Qaseem A, Snow V, Shekelle P, et al. Clinical Efficacy Assessment Subcommittee of the American College

of Physicians (ACP). Screening for osteoporosis in men: a clinical practice guideline from the American

College of Physicians. Ann Intern Med. 2008;148(9):680 – 84. [ACP website.]

http://annals.org/article.aspx?articleid=740825. Accessed March 23, 2016.

Rosen DS, the American Academy of Pediatrics Committee on Adolescence. Identification and

management of eating disorders in children and adolescents. Pediatrics. Revised 2010;26(6):1240 –

1253. Available at http://pediatrics.aappublications.org/content/126/6/1240.full.pdf. Accessed March

23, 2016.

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American Academy of Orthopaedic Surgeons (AAOS). Osteoporosis tests. Rev. 2007 [AAO website].

Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00413. March 23, 2016.

Bae DC, Stein BS. The diagnosis and treatment of osteoporosis in men on androgen deprivation therapy

for advanced carcinoma of the prostate. J Urol. 2004;172(6 Pt 1):2137 – 2144.

http://www.ncbi.nlm.nih.gov/pubmed/15538219. March 23, 2016.

Bell KJ, Hayen A, Macaskill P, et al. Value of routine monitoring of bone mineral density after starting

bisphosphonate treatment: secondary analysis of trial data. BMJ. 2009; 338:b2266.

Berger C, Langsetmo L, Joseph L, et al. Canadian Multicentre Osteoporosis Study Research Group.

Change in bone mineral density as a function of age in women and men and association with the use of

antiresorptive agents. CMAJ. 2008;178(13):1660 – 1668.

Berger C, Langsetmo L, Joseph L, et al. Association between change in BMD and fragility fracture in

women and men. J Bone Miner Res. February 2009;361 – 379.

Blake GM, Fogelman I. An update on dual-energy x-ray absorptiometry. Semin Nucl Med. 2010

Jan;40(1):62 – 73.

Blake GM, Fogelman I. Monitoring treatment for osteoporosis by using bone densitometry. Semin Nucl

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Burgess E, Nanes MS. Osteoporosis in men: pathophysiology, evaluation, and therapy. Curr Opin

Rheumatol. 2002;14(4):421 – 428.

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http://annals.org/article.aspx?articleid=740825

http://pediatrics.aappublications.org/content/126/6/1240.full.pdf

http://orthoinfo.aaos.org/topic.cfm?topic=A00413

http://www.ncbi.nlm.nih.gov/pubmed/15538219

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Carrasco F, Ruz M, Rojas P, et al. Changes in bone mineral density, body composition and adiponectin

levels in morbidly obese patients after bariatric surgery. Obes Surg. 2009;19(1):41 – 46.

Castro J, Toro J, laZaro L, et al. Bone mineral density in male adolescents with anorexia nervosa. J Am

Acad Child Adolesc Psychiatry. 2002;41(5):613 – 618.

Erlichman M, Holohan T. Bone densitometry. In Nuclear Medicine: Diagnosis and Therapy. Harbert,

Eckelman, Neurnann, eds. New York, NY: Thieme Medical Publishers, Inc.; 1996: 865 – 880.

Faulkner KG, Orwoll E. Implications in the use of T-scores for the diagnosis of osteoporosis in men. J Clin

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Fleischer J, Stein EM, Bessler M, et al. The decline in hip bone density after gastric bypass surgery is

associated with extent of weight loss. J Clin Endocrinol Metab. 2008;93(10):3735 – 3740.

Frost SA, Nguyen ND, Center JR, et al. Timing of repeat BMD measurements: development of an

absolute risk-based prognostic model. J Bone Miner Res. 2009;24(11):1800 – 1807.

Gafni RI, Baron J. Overdiagnosis of osteoporosis in children due to misinterpretation of dual-energy x-ray

absorptiometry (DEXA). J Pediatr. 2004;144(2):253 – 257.

Gourlay ML, Brown SA. Clinical considerations in premenopausal osteoporosis. Arch Intern Med.

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Gourlay M, Fine J, Preisser J, et al. Bone-Density Testing Interval and Transition to Osteoporosis in Older

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Koval PG, Easterling L, Pettus D, et al. Clinical inquiries. How should a DEXA scan be used to evaluate

bisphosphonate therapy for osteoporosis? J Fam Pract. 2005;54(1):65 – 71.

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U.S. Preventive Services Task Force Recommendation. Evidence Synthesis No. 77. AHRQ Publication No.

10-05145-EF-1. Rockville, Maryland: Agency for Healthcare Research and Quality, July 2010. Available at

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Nevitt MC, Cummings SR, Stone KL, et al. Risk factors for a first-incident radiographic vertebral fracture

in women less than or equal to 65 years of age: the study of osteoporotic fractures. J Bone Miner Res.

2005;20(1):131 – 140.

North American Menopause Society. Management of osteoporosis in postmenopausal women. [NAMS

website]. 2010. Available at: http://www.menopause.org/docs/default-document-

library/psosteo10.pdf?sfvrsn=2. Accessed March 23, 2016.

Oefelein MG, Resnick MI. The impact of osteoporosis in men treated for prostate cancer. Urol Clin North

Am. 2004;31(2):313 – 319.

http://www.ncbi.nlm.nih.gov/pubmed/12057569

http://www.niams.nih.gov/Health_Info/Bone/Bone_Health/Juvenile/juvenile_osteoporosis.asp

http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/men.asp

http://www.nof.org/aboutosteoporosis/detectingosteoporosis/diagnosing

http://www.ncbi.nlm.nih.gov/books/NBK45201/pdf/TOC.pdf

http://www.menopause.org/docs/default-document-library/psosteo10.pdf?sfvrsn=2

http://www.menopause.org/docs/default-document-library/psosteo10.pdf?sfvrsn=2

13

Osteogenesis Imperfecta (OI) Foundation. Bone densitometry in children and adults with OI. [OI

Foundation website]. February 1, 1998. Available at

http://www.oif.org/site/PageServer?pagename=BoneDens. Accessed March 23, 2016.

Perry HM 3rd, Morley JE. Osteoporosis in men: are we ready to diagnose and treat? Curr Rheumatol

Rep. 2001;3(3):240 – 244.

Qaseem A, Snow V, Shekelle P, et al; Clinical Efficacy Assessment Subcommittee of the American College

of Physicians. Screening for osteoporosis in men: A clinical practice guideline from the American College

of Physicians. Ann Intern Med. 2008;148(9):680 – 684.

Raisz LG. Clinical practice. Screening for osteoporosis. N Engl J Med. 2005;353(2):164 – 171.

Rosen CJ. Clinical practice. Postmenopausal osteoporosis. N Engl J Med. 2005;353(6):595 – 603.

Ross RW, Small EJ. Osteoporosis in men treated with androgen deprivation therapy for prostate cancer.

J Urol. 2002;167(5):1952 – 1956.

Sawka AM, Papaioannou A, Josse RG, et al; The CaMos Research Group. What is the number of older

Canadians needed to screen by measurement of bone density to detect an undiagnosed case of

osteoporosis? a population-based study from CaMos. J Clin Densitom. 2006;9(4):413 – 418.

Siris ES, Brenneman SK, Miller PD, et al. Predictive value of low BMD for 1-year fracture outcomes is

similar for postmenopausal women ages 50-64 and 65 and older: results from the National Osteoporosis

Risk Assessment (NORA). J Bone Miner Res. 2004;19(8):1215 – 1220.

U.S. Department of Health and Human Services, Office of the Surgeon General. The 2004 Surgeon

General’s report on bone health and osteoporosis: What it means to you.

www.ncbi.nlm.nih.gov/books/NBK45513/. Accessed March 23, 2016.

U.S. Preventive Services Task Force (USPSTF). Screening for osteoporosis in postmenopausal women.

[USPTF website.] January 2011.

http://www.uspreventiveservicestaskforce.org/uspstf10/osteoporosis/osteors.pdf. Accessed March 23,

2016.

Valderas JP, Velasco S, Solari S, et al. Increase of bone resorption and the parathyroid hormone in

postmenopausal women in the long-term after Roux-en-Y gastric bypass. Obes Surg. 2009;19(8):1132 –

1138.

Vanderschueren D, Boonen S, Bouillon R. Osteoporosis and osteoporotic fractures in men: a clinical

perspective (abstract). Baillieres Best Pract Res Clin Endocrinol Metab. 2000:14(2):299 – 315.

http://www.oif.org/site/PageServer?pagename=BoneDens

http://www.ncbi.nlm.nih.gov/books/NBK45513/

http://www.uspreventiveservicestaskforce.org/uspstf10/osteoporosis/osteors.pdf

14

Vilarrasa N, San Jose P, Garcia I, et al. Evaluation of bone mineral density in morbidly obese women after

gastric bypass: 3-year follow-up. Obstet Surg. 2010 [Epub ahead of print].

Woodson GC. Risk factors for osteoporosis in postmenopausal African-American women. Curr Med Res

Opin. 2004;20(10):1681 – 1687.

Writing Group for the ISCD Position Development Conference. Diagnosis of osteoporosis in men,

premenopausal women, and children. J Clin Densitom. 2004;7(1):17 – 26.

Clinical trials:

Searched clinicaltrials.gov on March 23, 2016, using terms “bone density in osteogenesis.” | Open

Studies. 49 studies found, one relevant.

Creighton University Medical Center, University of Nebraska Study Comparing Bone Loss in Women Who

Take Calcium and Vitamin D With Women Who Also Take Risedronate or Exercise (HOPE).

NCT02186600. First received: July 7, 2014. Last updated: June 8, 2015. ClinicalTrials.gov website.

https://clinicaltrials.gov/ct2/show/NCT02186600?term=Bone+Density+in+Osteogenesis&recr=Open&no

_unk=Y&rank=17. Accessed March 23, 2016.

CMS National Coverage Determinations (NCDs):

150.3: Bone (mineral) density studies. Effective. January 1, 2007. CMS website .

https://www.cms.gov/medicarecoveragedatabase/details/ncddetails.aspx?NCDId=256&ncdver=2&DocI

D=150.3&. Accessed March 23, 2016.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Pub 100-02: Medicare Benefit

Policy. Bone Mass Measurement (BMMs); NCD 80.5 , Transmittal 70, change request 5521. May 11,

2007.

CMSwebsite:https://www.cms.gov/RegulationsandGuidance/Guidance/Transmittals/Downloads/R70BP.

pdf. Accessed March 23, 2016.

Local Coverage Determinations (LCDs):

L36356 Bone Mineral Density Studies Effective. 10/01/2015. CMS website

https://www.cms.gov/medicarecoveragedatabase/details/lcddetails.aspx?LCDId=36356&ver=11&Searc

hType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7c

MCD&ArticleType=SAD%7cEd&PolicyType=Final&s=All&KeyWord=Bone+(mineral)+density+studies&Key

WordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=IAAAABAAAAAAAA%3d%3d&. Accessed

March 23, 2016.

Commonly submitted codes

https://www.cms.gov/medicarecoveragedatabase/details/ncddetails.aspx?NCDId=256&ncdver=2&DocID=150.3&

https://www.cms.gov/medicarecoveragedatabase/details/ncddetails.aspx?NCDId=256&ncdver=2&DocID=150.3&

https://www.cms.gov/RegulationsandGuidance/Guidance/Transmittals/Downloads/R70BP.pdf

https://www.cms.gov/RegulationsandGuidance/Guidance/Transmittals/Downloads/R70BP.pdf

https://www.cms.gov/medicarecoveragedatabase/details/lcddetails.aspx?LCDId=36356&ver=11&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=SAD%7cEd&PolicyType=Final&s=All&KeyWord=Bone+(mineral)+density+studies&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=IAAAABAAAAAAAA%3d%3d&




15

Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is

not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and

bill accordingly.

CPT Code Description Comments

77080 Dual energy X-ray absorptiometry (DXA), bone density study, 1 or more sites;

axial skeleton (e.g., hips, pelvis, spine)

77081 Dual energy X-ray absorptiometry (DXA), bone density study, 1 or more sites;

appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

77085 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites;

axial skeleton (e.g., hips, pelvis, spine), including vertebral fracture

assessment

77086 Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA)

ICD-10 Code Description Comments

D56.0 Alpha thalassemia

D56.1 Beta thalassemia

D56.8 Other thalassemias

D57.819 Other sickle-cell disorders with crisis, unspecified

E01.1 Iodine-deficiency related multinodular (endemic) goiter

E04.1 Nontoxic single thyroid nodule

E04.2 Nontoxic multinodular goiter

E04.8 Other specified nontoxic goiter

E04.9 Nontoxic goiter, unspecified

E07.9 Disorder of thyroid, unspecified

E21.0 Primary hyperparathyroidism

E21.1 Secondary hyperparathyroidism, not elsewhere classified

E21.2 Other hyperparathyroidism

E21.3 Hyperparathyroidism, unspecified

E28.310 Symptomatic premature menopause

E28.319 Asymptomatic premature menopause

E28.39 Other primary ovarian failure

E34.2 Ectopic hormone secretion, not elsewhere classified

E55.0 Rickets, active

E55.9 Vitamin D deficiency, unspecified

E58 Dietary calcium deficiency

E59 Dietary selenium deficiency

E60 Dietary zinc deficiency

E61.0 Copper deficiency

E61.1 Iron deficiency

E61.2 Magnesium deficiency

E61.3 Manganese deficiency

E61.4 Chromium deficiency

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E61.5 Molybdenum deficiency

E61.6 Vanadium deficiency

E61.8 Deficiency of other specified nutrient elements

E64.3 Sequelae of rickets

E83.118 Other hemochromatosis

E83.119 Hemochromatosis, unspecified

M48.50XA Collapsed vertebra, not elsewhere classified, site unspecified, initial

encounter for fracture

M48.51XA Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region,

initial encounter for fracture

M48.52XA Collapsed vertebra, not elsewhere classified, cervical region, initial


M48.53XA Collapsed vertebra, not elsewhere classified, cervicothoracic region, initial


M48.54XA Collapsed vertebra, not elsewhere classified, thoracic region, initial


M48.55XA Collapsed vertebra, not elsewhere classified, thoracolumbar region, initial


M48.56XA Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter

for fracture

M48.57XA Collapsed vertebra, not elsewhere classified, lumbosacral region, initial


M48.58XA Collapsed vertebra, not elsewhere classified, sacral and sacrococcygeal

region, initial encounter for fracture

M80.00XA Age-related osteoporosis with current pathological fracture, unspecified site,


M80.011A Age-related osteoporosis with current pathological fracture, right shoulder,


M80.012A Age-related osteoporosis with current pathological fracture, left shoulder,


M80.019A Age-related osteoporosis with current pathological fracture, unspecified

shoulder, initial encounter for fracture

M80.021A Age-related osteoporosis with current pathological fracture, right humerus,


M80.022A Age-related osteoporosis with current pathological fracture, left humerus,



humerus, initial encounter for fracture

M80.031A Age-related osteoporosis with current pathological fracture, right forearm,


M80.032A Age-related osteoporosis with current pathological fracture, left forearm,



forearm, initial encounter for fracture

M80.041A Age-related osteoporosis with current pathological fracture, right hand, initial


M80.042A Age-related osteoporosis with current pathological fracture, left hand, initial

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17




hand, initial encounter for fracture

M80.051A Age-related osteoporosis with current pathological fracture, right femur,


M80.052A Age-related osteoporosis with current pathological fracture, left femur, initial



femur, initial encounter for fracture

M80.061A Age-related osteoporosis with current pathological fracture, right lower leg,


M80.062A Age-related osteoporosis with current pathological fracture, left lower leg,



lower leg, initial encounter for fracture

M80.071A Age-related osteoporosis with current pathological fracture, right ankle and

foot, initial encounter for fracture

M80.072A Age-related osteoporosis with current pathological fracture, left ankle and



ankle and foot, initial encounter for fracture

M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e),


M80.80XA Other osteoporosis with current pathological fracture, unspecified site, initial


M80.811A Other osteoporosis with current pathological fracture, right shoulder, initial


M80.812A Other osteoporosis with current pathological fracture, left shoulder, initial


M80.819A Other osteoporosis with current pathological fracture, unspecified shoulder,


M80.821A Other osteoporosis with current pathological fracture, right humerus, initial


M80.822A Other osteoporosis with current pathological fracture, left humerus, initial


M80.829A Other osteoporosis with current pathological fracture, unspecified humerus,


M80.831A Other osteoporosis with current pathological fracture, right forearm, initial


M80.832A Other osteoporosis with current pathological fracture, left forearm, initial


M80.839A Other osteoporosis with current pathological fracture, unspecified forearm,


M80.841A Other osteoporosis with current pathological fracture, right hand, initial


M80.842A Other osteoporosis with current pathological fracture, left hand, initial

























18


M80.849A Other osteoporosis with current pathological fracture, unspecified hand,


M80.851A Other osteoporosis with current pathological fracture, right femur, initial


M80.852A Other osteoporosis with current pathological fracture, left femur, initial


M80.859A Other osteoporosis with current pathological fracture, unspecified femur,


M80.861A Other osteoporosis with current pathological fracture, right lower leg, initial


M80.862A Other osteoporosis with current pathological fracture, left lower leg, initial


M80.869A Other osteoporosis with current pathological fracture, unspecified lower leg,


M80.871A Other osteoporosis with current pathological fracture, right ankle and foot,


M80.872A Other osteoporosis with current pathological fracture, left ankle and foot,


M80.879A Other osteoporosis with current pathological fracture, unspecified ankle and


M80.88XA Other osteoporosis with current pathological fracture, vertebra(e), initial


M83.0 Puerperal osteomalacia

M83.1 Senile osteomalacia

M83.2 Adult osteomalacia due to malabsorption

M83.3 Adult osteomalacia due to malnutri

M83.4 Aluminum bone disease

M83.5 Other drug-induced osteomalacia in adults

M83.8 Other adult osteomalacia

M83.9 Adult osteomalacia, unspecified

M84.40XA Pathological fracture, unspecified site, initial encounter for fracture

M84.411A Pathological fracture, right shoulder, initial encounter for fracture

M84.412A Pathological fracture, left shoulder, initial encounter for fracture

M84.419A Pathological fracture, unspecified shoulder, initial encounter for fracture

M84.421A Pathological fracture, right humerus, initial encounter for fracture

M84.422A Pathological fracture, left humerus, initial encounter for fracture

M84.429A Pathological fracture, unspecified humerus, initial encounter for fracture

M84.431A Pathological fracture, right ulna, initial encounter for fracture

M84.432A Pathological fracture, left ulna, initial encounter for fracture

M84.433A Pathological fracture, right radius, initial encounter for fracture

M84.434A Pathological fracture, left radius, initial encounter for fracture

M84.439A Pathological fracture, unspecified ulna and radius, initial encounter for

fracture

M84.441A Pathological fracture, right hand, initial encounter for fracture

M84.442A Pathological fracture, left hand, initial encounter for fracture

M84.443A Pathological fracture, unspecified hand, initial encounter for fracture



























19


M84.444A Pathological fracture, right finger(s), initial encounter for fracture

M84.445A Pathological fracture, left finger(s), initial encounter for fracture

M84.446A Pathological fracture, unspecified finger(s), initial encounter for fracture

M84.451A Pathological fracture, right femur, initial encounter for fracture

M84.452A Pathological fracture, left femur, initial encounter for fracture

M84.453A Pathological fracture, unspecified femur, initial encounter for fracture

M84.454A Pathological fracture, pelvis, initial encounter for fracture

M84.459A Pathological fracture, hip, unspecified, initial encounter for fracture

M84.461A Pathological fracture, right tibia, initial encounter for fracture

M84.462A Pathological fracture, left tibia, initial encounter for fracture

M84.463A Pathological fracture, right fibula, initial encounter for fracture

M84.464A Pathological fracture, left fibula, initial encounter for fracture

M84.469A Pathological fracture, unspecified tibia and fibula, initial encounter for

fracture

M84.471A Pathological fracture, right ankle, initial encounter for fracture

M84.472A Pathological fracture, left ankle, initial encounter for fracture

M84.473A Pathological fracture, unspecified ankle, initial encounter for fracture

M84.474A Pathological fracture, right foot, initial encounter for fracture

M84.475A Pathological fracture, left foot, initial encounter for fracture

M84.476A Pathological fracture, unspecified foot, initial encounter for fracture

M84.477A Pathological fracture, right toe(s), initial encounter for fracture

M84.478A Pathological fracture, left toe(s), initial encounter for fracture

M84.479A Pathological fracture, unspecified toe(s), initial encounter for fracture

M84.48XA Pathological fracture, other site, initial encounter for fracture

M84.50XA Pathological fracture in neoplastic disease, unspecified site, initial encounter

for fracture

M84.511A Pathological fracture in neoplastic disease, right shoulder, initial encounter

for fracture

M84.512A Pathological fracture in neoplastic disease, left shoulder, initial encounter for

fracture

M84.519A Pathological fracture in neoplastic disease, unspecified shoulder, initial


M84.521A Pathological fracture in neoplastic disease, right humerus, initial encounter

for fracture

M84.522A Pathological fracture in neoplastic disease, left humerus, initial encounter for

fracture

M84.529A Pathological fracture in neoplastic disease, unspecified humerus, initial


M84.531A Pathological fracture in neoplastic disease, right ulna, initial encounter for

fracture

M84.532A Pathological fracture in neoplastic disease, left ulna, initial encounter for

fracture

M84.533A Pathological fracture in neoplastic disease, right radius, initial encounter for

fracture

M84.534A Pathological fracture in neoplastic disease, left radius, initial encounter for

fracture



































20


M84.539A Pathological fracture in neoplastic disease, unspecified ulna and radius,


M84.541A Pathological fracture in neoplastic disease, right hand, initial encounter for

fracture

M84.542A Pathological fracture in neoplastic disease, left hand, initial encounter for

fracture

M84.549A Pathological fracture in neoplastic disease, unspecified hand, initial


M84.550A Pathological fracture in neoplastic disease, pelvis, initial encounter for

fracture

M84.551A Pathological fracture in neoplastic disease, right femur, initial encounter for

fracture

M84.552A Pathological fracture in neoplastic disease, left femur, initial encounter for

fracture

M84.553A Pathological fracture in neoplastic disease, unspecified femur, initial


M84.559A Pathological fracture in neoplastic disease, hip, unspecified, initial encounter

for fracture

M84.561A Pathological fracture in neoplastic disease, right tibia, initial encounter for

fracture

M84.562A Pathological fracture in neoplastic disease, left tibia, initial encounter for

fracture

M84.563A Pathological fracture in neoplastic disease, right fibula, initial encounter for

fracture

M84.564A Pathological fracture in neoplastic disease, left fibula, initial encounter for

fracture

M84.569A Pathological fracture in neoplastic disease, unspecified tibia and fibula,


M84.571A Pathological fracture in neoplastic disease, right ankle, initial encounter for

fracture

M84.572A Pathological fracture in neoplastic disease, left ankle, initial encounter for

fracture

M84.573A Pathological fracture in neoplastic disease, unspecified ankle, initial


M84.574A Pathological fracture in neoplastic disease, right foot, initial encounter for

fracture

M84.575A Pathological fracture in neoplastic disease, left foot, initial encounter for

fracture

M84.576A Pathological fracture in neoplastic disease, unspecified foot, initial encounter

for fracture

M84.58XA Pathological fracture in neoplastic disease, other specified site, initial


M84.60XA Pathological fracture in other disease, unspecified site, initial encounter for

fracture

M84.611A Pathological fracture in other disease, right shoulder, initial encounter for

fracture

M84.612A Pathological fracture in other disease, left shoulder, initial encounter for

























21


fracture

M84.619A Pathological fracture in other disease, unspecified shoulder, initial encounter

for fracture

M84.621A Pathological fracture in other disease, right humerus, initial encounter for

fracture

M84.622A Pathological fracture in other disease, left humerus, initial encounter for

fracture

M84.629A Pathological fracture in other disease, unspecified humerus, initial encounter

for fracture

M84.631A Pathological fracture in other disease, right ulna, initial encounter for fracture

M84.632A Pathological fracture in other disease, left ulna, initial encounter for fracture

M84.633A Pathological fracture in other disease, right radius, initial encounter for

fracture

M84.634A Pathological fracture in other disease, left radius, initial encounter for

fracture

M84.639A Pathological fracture in other disease, unspecified ulna and radius, initial


M84.641A Pathological fracture in other disease, right hand, initial encounter for

fracture

M84.642A Pathological fracture in other disease, left hand, initial encounter for fracture

M84.649A Pathological fracture in other disease, unspecified hand, initial encounter for

fracture

M84.650A Pathological fracture in other disease, pelvis, initial encounter for fracture

M84.651A Pathological fracture in other disease, right femur, initial encounter for

fracture

M84.652A Pathological fracture in other disease, left femur, initial encounter for

fracture

M84.653A Pathological fracture in other disease, unspecified femur, initial encounter

for fracture

M84.659A Pathological fracture in other disease, hip, unspecified, initial encounter for

fracture

M84.661A Pathological fracture in other disease, right tibia, initial encounter for fracture

M84.662A Pathological fracture in other disease, left tibia, initial encounter for fracture

M84.663A Pathological fracture in other disease, right fibula, initial encounter for

fracture

M84.664A Pathological fracture in other disease, left fibula, initial encounter for fracture

M84.669A Pathological fracture in other disease, unspecified tibia and fibula, initial


M84.671A Pathological fracture in other disease, right ankle, initial encounter for

fracture

M84.672A Pathological fracture in other disease, left ankle, initial encounter for fracture

M84.673A Pathological fracture in other disease, unspecified ankle, initial encounter for

fracture

M84.674A Pathological fracture in other disease, right foot, initial encounter for fracture

M84.675A Pathological fracture in other disease, left foot, initial encounter for fracture

M84.676A Pathological fracture in other disease, unspecified foot, initial encounter for





























22


fracture

M84.68XA Pathological fracture in other disease, other site, initial encounter for fracture

M84.68XA Pathological fracture in other disease, other site, initial encounter for fracture

S12.000A Unspecified displaced fracture of first cervical vertebra, initial encounter for

closed fracture

S12.000B Unspecified displaced fracture of first cervical vertebra, initial encounter for

open fracture

S12.001A Unspecified nondisplaced fracture of first cervical vertebra, initial encounter

for closed fracture

S12.001B Unspecified nondisplaced fracture of first cervical vertebra, initial encounter

for open fracture

S12.01XA Stable burst fracture of first cervical vertebra, initial encounter for closed

fracture

S12.02XA Unstable burst fracture of first cervical vertebra, initial encounter for closed

fracture

S12.030A Displaced posterior arch fracture of first cervical vertebra, initial encounter

for closed fracture

S12.031A Nondisplaced posterior arch fracture of first cervical vertebra, initial

encounter for closed fracture

S12.040A Displaced lateral mass fracture of first cervical vertebra, initial encounter for

closed fracture

S12.041A Nondisplaced lateral mass fracture of first cervical vertebra, initial encounter

for closed fracture

S12.090A Other displaced fracture of first cervical vertebra, initial encounter for closed

fracture

S12.091A Other nondisplaced fracture of first cervical vertebra, initial encounter for

closed fracture

S12.100A Unspecified displaced fracture of second cervical vertebra, initial encounter

for closed fracture

S12.101A Unspecified nondisplaced fracture of second cervical vertebra, initial


S12.110A Anterior displaced Type II dens fracture, initial encounter for closed fracture

S12.111A Posterior displaced Type II dens fracture, initial encounter for closed fracture

S12.112A Nondisplaced Type II dens fracture, initial encounter for closed fracture

S12.120A Other displaced dens fracture, initial encounter for closed fracture

S12.121A Other nondisplaced dens fracture, initial encounter for closed fracture

S12.130A Unspecified traumatic displaced spondylolisthesis of second cervical

vertebra, initial encounter for closed fracture

S12.131A Unspecified traumatic nondisplaced spondylolisthesis of second cervical


S12.14XA Type III traumatic spondylolisthesis of second cervical vertebra, initial


S12.150A Other traumatic displaced spondylolisthesis of second cervical vertebra,

initial encounter for closed fracture

S12.151A Other traumatic nondisplaced spondylolisthesis of second cervical vertebra,




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23


S12.190A Other displaced fracture of second cervical vertebra, initial encounter for

closed fracture

S12.191A Other nondisplaced fracture of second cervical vertebra, initial encounter for

closed fracture

S12.200A Unspecified displaced fracture of third cervical vertebra, initial encounter for

closed fracture

S12.201A Unspecified nondisplaced fracture of third cervical vertebra, initial encounter

for closed fracture

S12.230A Unspecified traumatic displaced spondylolisthesis of third cervical vertebra,


S12.231A Unspecified traumatic nondisplaced spondylolisthesis of third cervical


S12.24XA Type III traumatic spondylolisthesis of third cervical vertebra, initial


S12.250A Other traumatic displaced spondylolisthesis of third cervical vertebra, initial


S12.251A Other traumatic nondisplaced spondylolisthesis of third cervical vertebra,


S12.290A Other displaced fracture of third cervical vertebra, initial encounter for closed

fracture

S12.291A Other nondisplaced fracture of third cervical vertebra, initial encounter for

closed fracture

S12.300A Unspecified displaced fracture of fourth cervical vertebra, initial encounter

for closed fracture

S12.301A Unspecified nondisplaced fracture of fourth cervical vertebra, initial


S12.330A Unspecified traumatic displaced spondylolisthesis of fourth cervical vertebra,


S12.331A Unspecified traumatic nondisplaced spondylolisthesis of fourth cervical


S12.34XA Type III traumatic spondylolisthesis of fourth cervical vertebra, initial


S12.350A Other traumatic displaced spondylolisthesis of fourth cervical vertebra, initial


S12.351A Other traumatic nondisplaced spondylolisthesis of fourth cervical vertebra,


S12.390A Other displaced fracture of fourth cervical vertebra, initial encounter for

closed fracture

S12.391A Other nondisplaced fracture of fourth cervical vertebra, initial encounter for

closed fracture

S12.400A Unspecified displaced fracture of fifth cervical vertebra, initial encounter for

closed fracture

S12.401A Unspecified nondisplaced fracture of fifth cervical vertebra, initial encounter

for closed fracture

S12.430A Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra,


S12.431A Unspecified traumatic nondisplaced spondylolisthesis of fifth cervical

























24



S12.44XA Type III traumatic spondylolisthesis of fifth cervical vertebra, initial encounter

for closed fracture

S12.450A Other traumatic displaced spondylolisthesis of fifth cervical vertebra, initial


S12.451A Other traumatic nondisplaced spondylolisthesis of fifth cervical vertebra,


S12.490A Other displaced fracture of fifth cervical vertebra, initial encounter for closed

fracture

S12.491A Other nondisplaced fracture of fifth cervical vertebra, initial encounter for

closed fracture

S12.500A Unspecified displaced fracture of sixth cervical vertebra, initial encounter for

closed fracture

S12.501A Unspecified nondisplaced fracture of sixth cervical vertebra, initial encounter

for closed fracture

S12.530A Unspecified traumatic displaced spondylolisthesis of sixth cervical vertebra,


S12.531A Unspecified traumatic nondisplaced spondylolisthesis of sixth cervical


S12.54XA Type III traumatic spondylolisthesis of sixth cervical vertebra, initial


S12.550A Other traumatic displaced spondylolisthesis of sixth cervical vertebra, initial


S12.551A Other traumatic nondisplaced spondylolisthesis of sixth cervical vertebra,


S12.590A Other displaced fracture of sixth cervical vertebra, initial encounter for

closed fracture

S12.591A Other nondisplaced fracture of sixth cervical vertebra, initial encounter for

closed fracture

S12.600A Unspecified displaced fracture of seventh cervical vertebra, initial encounter

for closed fracture

S12.601A Unspecified nondisplaced fracture of seventh cervical vertebra, initial


S12.630A Unspecified traumatic displaced spondylolisthesis of seventh cervical


S12.631A Unspecified traumatic nondisplaced spondylolisthesis of seventh cervical


S12.64XA Type III traumatic spondylolisthesis of seventh cervical vertebra, initial


S12.650A Other traumatic displaced spondylolisthesis of seventh cervical vertebra,


S12.651A Other traumatic nondisplaced spondylolisthesis of seventh cervical vertebra,


S12.690A Other displaced fracture of seventh cervical vertebra, initial encounter for

closed fracture

S12.691A Other nondisplaced fracture of seventh cervical vertebra, initial encounter

for closed fracture
























25


S12.9XXA Fracture of neck, unspecified, initial encounter

S14.101A Unspecified injury at C1 level of cervical spinal cord, initial encounter







S14.109A Unspecified injury at unspecified level of cervical spinal cord, initial

encounter

S14.111A Complete lesion at C1 level of cervical spinal cord, initial encounter







S14.119A Complete lesion at unspecified level of cervical spinal cord, initial encounter

S14.121A Central cord syndrome at C1 level of cervical spinal cord, initial encounter







S14.129A Central cord syndrome at unspecified level of cervical spinal cord, initial

encounter

S14.131A Anterior cord syndrome at C1 level of cervical spinal cord, initial encounter

S12.551A Other traumatic nondisplaced spondylolisthesis of sixth cervical vertebra,


S12.590A Other displaced fracture of sixth cervical vertebra, initial encounter for

closed fracture

S12.591A Other nondisplaced fracture of sixth cervical vertebra, initial encounter for

closed fracture

S12.600A Unspecified displaced fracture of seventh cervical vertebra, initial encounter

for closed fracture

S12.601A Unspecified nondisplaced fracture of seventh cervical vertebra, initial


S12.630A Unspecified traumatic displaced spondylolisthesis of seventh cervical


S12.631A Unspecified traumatic nondisplaced spondylolisthesis of seventh cervical


S12.64XA Type III traumatic spondylolisthesis of seventh cervical vertebra, initial


S12.650A Other traumatic displaced spondylolisthesis of seventh cervical vertebra,


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26


S12.651A Other traumatic nondisplaced spondylolisthesis of seventh cervical vertebra,


S12.690A Other displaced fracture of seventh cervical vertebra, initial encounter for

closed fracture

S12.691A Other nondisplaced fracture of seventh cervical vertebra, initial encounter

for closed fracture

S12.9XXA Fracture of neck, unspecified, initial encounter








S14.109A Unspecified injury at unspecified level of cervical spinal cord, initial

encounter








S14.119A Complete lesion at unspecified level of cervical spinal cord, initial encounter








S14.129A Central cord syndrome at unspecified level of cervical spinal cord, initial

encounter








S14.139A Anterior cord syndrome at unspecified level of cervical spinal cord, initial

encounter

S14.151A Other incomplete lesion at C1 level of cervical spinal cord, initial encounter












































27




S14.157A Other incomplete lesion at C7 level of

S22.009A Unspecified fracture of unspecified thoracic vertebra, initial encounter for

closed fracture

S22.010A Wedge compression fracture of first thoracic vertebra, initial encounter for

closed fracture

S22.011A Stable burst fracture of first thoracic vertebra, initial encounter for closed

fracture

S22.012A Unstable burst fracture of first thoracic vertebra, initial encounter for closed

fracture

S22.018A Other fracture of first thoracic vertebra, initial encounter for closed fracture

S22.019A Unspecified fracture of first thoracic vertebra, initial encounter for closed

fracture

S22.020A Wedge compression fracture of second thoracic vertebra, initial encounter

for closed fracture

S22.021A Stable burst fracture of second thoracic vertebra, initial encounter for closed

fracture

S22.022A Unstable burst fracture of second thoracic vertebra, initial encounter for

closed fracture

S22.028A Other fracture of second thoracic vertebra, initial encounter for closed

fracture

S22.029A Unspecified fracture of second thoracic vertebra, initial encounter for closed

fracture

S22.029A Unspecified fracture of second thoracic vertebra, initial encounter for closed

fracture

S22.030A Wedge compression fracture of third thoracic vertebra, initial encounter for

closed fracture

S22.031A Stable burst fracture of third thoracic vertebra, initial encounter for closed

fracture

S22.032A Unstable burst fracture of third thoracic vertebra, initial encounter for closed

fracture

S22.038A Other fracture of third thoracic vertebra, initial encounter for closed fracture

S22.039A Unspecified fracture of third thoracic vertebra, initial encounter for closed

fracture

S22.040A Wedge compression fracture of fourth thoracic vertebra, initial encounter for

closed fracture

S22.041A Stable burst fracture of fourth thoracic vertebra, initial encounter for closed

fracture

S22.042A Unstable burst fracture of fourth thoracic vertebra, initial encounter for

closed fracture

S22.048A Other fracture of fourth thoracic vertebra, initial encounter for closed fracture

S22.049A Unspecified fracture of fourth thoracic vertebra, initial encounter for closed

fracture

S22.050A Wedge compression fracture of T5-T6 vertebra, initial encounter for closed

fracture

S22.051A Stable burst fracture of T5-T6 vertebra, initial encounter for closed fracture




























28


S22.052A Unstable burst fracture of T5-T6 vertebra, initial encounter for closed

fracture

S22.058A Other fracture of T5-T6 vertebra, initial encounter for closed fracture

S22.059A Unspecified fracture of T5-T6 vertebra, initial encounter for closed fracture


fracture



fracture

S22.068A Other fracture of T7-T8 thoracic vertebra, initial encounter for closed fracture

S22.068B Other fracture of T7-T8 thoracic vertebra, initial encounter for open fracture



fracture



fracture



S22.080A Wedge compression fracture of T11-T12 vertebra, initial encounter for

closed fracture

S22.081A Stable burst fracture of T11-T12 vertebra, initial encounter for closed

fracture


fracture


S22.089A Unspecified fracture of T11-T12 vertebra, initial encounter for closed

fracture

S24.101A Unspecified injury at T1 level of thoracic spinal cord, initial encounter

S24.102A Unspecified injury at T2-T6 level of thoracic spinal cord, initial encounter



S24.109A Unspecified injury at unspecified level of thoracic spinal cord, initial

encounter

S24.109D Unspecified injury at unspecified level of thoracic spinal cord, subsequent

encounter

S24.109S Unspecified injury at unspecified level of thoracic spinal cord, sequela

S24.111A Complete lesion at T1 level of thoracic spinal cord, initial encounter

S24.112A Complete lesion at T2-T6 level of thoracic spinal cord, initial encounter



S24.119A Complete lesion at unspecified level of thoracic spinal cord, initial encounter

S24.131A Anterior cord syndrome at T1 level of thoracic spinal cord, initial encounter

S24.132A Anterior cord syndrome at T2-T6 level of thoracic spinal cord, initial

encounter


























https://www.encoderprofp.com/epro4payers/i10cmHandler.do?_k=201*S24.109D&_a=view

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29


encounter


encounter

S24.139A Anterior cord syndrome at unspecified level of thoracic spinal cord, initial

encounter

S24.151A Other incomplete lesion at T1 level of thoracic spinal cord, initial encounter

S24.152A Other incomplete lesion at T2-T6 level of thoracic spinal cord, initial

encounter


encounter


encounter

S24.159A Other incomplete lesion at unspecified level of thoracic spinal cord, initial

encounter

S32.000A Wedge compression fracture of unspecified lumbar vertebra, initial


S32.000B Wedge compression fracture of unspecified lumbar vertebra, initial

encounter for open fracture

S32.001A Stable burst fracture of unspecified lumbar vertebra, initial encounter for

closed fracture

S32.002A Unstable burst fracture of unspecified lumbar vertebra, initial encounter for

closed fracture

S32.008A Other fracture of unspecified lumbar vertebra, initial encounter for closed

fracture

S32.009A Unspecified fracture of unspecified lumbar vertebra, initial encounter for

closed fracture


closed fracture


closed fracture


closed fracture


closed fracture

S32.009B Unspecified fracture of unspecified lumbar vertebra, initial encounter for

open fracture

S32.010A Wedge compression fracture of first lumbar vertebra, initial encounter for

closed fracture

S32.011A Stable burst fracture of first lumbar vertebra, initial encounter for closed

fracture

S32.012A Unstable burst fracture of first lumbar vertebra, initial encounter for closed

fracture

S32.018A Other fracture of first lumbar vertebra, initial encounter for closed fracture

S32.019A Unspecified fracture of first lumbar vertebra, initial encounter for closed

fracture


fracture

























30



fracture

S32.020A Wedge compression fracture of second lumbar vertebra, initial encounter for

closed fracture

S32.021A Stable burst fracture of second lumbar vertebra, initial encounter for closed

fracture


S24.109A Unspecified injury at unspecified level of thoracic spinal cord, initial

encounter

S24.109D Unspecified injury at unspecified level of thoracic spinal cord, subsequent

encounter

S24.109S Unspecified injury at unspecified level of thoracic spinal cord, sequela

S24.111A Complete lesion at T1 level of thoracic spinal cord, initial encounter




S24.119A Complete lesion at unspecified level of thoracic spinal cord, initial encounter

S24.131A Anterior cord syndrome at T1 level of thoracic spinal cord, initial encounter


encounter


encounter


encounter

S24.139A Anterior cord syndrome at unspecified level of thoracic spinal cord, initial

encounter

S24.151A Other incomplete lesion at T1 level of thoracic spinal cord, initial encounter


encounter


encounter


encounter

S24.159A Other incomplete lesion at unspecified level of thoracic spinal cord, initial

encounter

S32.000A Wedge compression fracture of unspecified lumbar vertebra, initial


S32.000B Wedge compression fracture of unspecified lumbar vertebra, initial

encounter for open fracture

S32.001A Stable burst fracture of unspecified lumbar vertebra, initial encounter for

closed fracture

S32.002A Unstable burst fracture of unspecified lumbar vertebra, initial encounter for

closed fracture

S32.008A Other fracture of unspecified lumbar vertebra, initial encounter for closed

fracture







https://www.encoderprofp.com/epro4payers/i10cmHandler.do?_k=201*S24.109D&_a=view

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31


closed fracture


closed fracture


closed fracture


closed fracture


closed fracture

S32.010A Wedge compression fracture of first lumbar vertebra, initial encounter for

closed fracture

S32.011A Stable burst fracture of first lumbar vertebra, initial encounter for closed

fracture

S32.012A Unstable burst fracture of first lumbar vertebra, initial encounter for closed

fracture

S32.018A Other fracture of first lumbar vertebra, initial encounter for closed fracture


fracture


fracture


fracture

S32.020A Wedge compression fracture of second lumbar vertebra, initial encounter for

closed fracture

S32.021A Stable burst fracture of second lumbar vertebra, initial encounter for closed

fracture

S32.022A Unstable burst fracture of second lumbar vertebra, initial encounter for

closed fracture

S32.028A Other fracture of second lumbar vertebra, initial encounter for closed

fracture

S32.029A Unspecified fracture of second lumbar vertebra, initial encounter for closed

fracture


fracture


fracture

S32.030A Wedge compression fracture of third lumbar vertebra, initial encounter for

closed fracture

S32.031A Stable burst fracture of third lumbar vertebra, initial encounter for closed

fracture

S32.032A Unstable burst fracture of third lumbar vertebra, initial encounter for closed

fracture

S32.038A Other fracture of third lumbar vertebra, initial encounter for closed fracture

S32.039A Unspecified fracture of third lumbar vertebra, initial encounter for closed

fracture


fracture

























32



fracture

S32.040A Wedge compression fracture of fourth lumbar vertebra, initial encounter for

closed fracture

S32.041A Stable burst fracture of fourth lumbar vertebra, initial encounter for closed

fracture

S32.042A Unstable burst fracture of fourth lumbar vertebra, initial encounter for closed

fracture

S32.048A Other fracture of fourth lumbar vertebra, initial encounter for closed fracture

S32.049A Unspecified fracture of fourth lumbar vertebra, initial encounter for closed

fracture


fracture


fracture

S32.050A Wedge compression fracture of fifth lumbar vertebra, initial encounter for

closed fracture

S32.051A Stable burst fracture of fifth lumbar vertebra, initial encounter for closed

fracture

S32.052A Unstable burst fracture of fifth lumbar vertebra, initial encounter for closed

fracture

S32.058A Other fracture of fifth lumbar vertebra, initial encounter for closed fracture

S32.059A Unspecified fracture of fifth lumbar vertebra, initial encounter for closed

fracture


fracture


fracture

S32.10XA Unspecified fracture of sacrum, initial encounter for closed fracture







S32.10XB Unspecified fracture of sacrum, initial encounter for open fracture


S32.10XB Unspecified fracture of sacrum, initial encounter for closed fracture





S32.110A Nondisplaced Zone I fracture of sacrum, initial encounter for closed fracture

S32.111A Minimally displaced Zone I fracture of sacrum, initial encounter for closed

fracture

S32.112A Severely displaced Zone I fracture of sacrum, initial encounter for closed























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33


fracture

S32.119A Unspecified Zone I fracture of sacrum, initial encounter for closed fracture

S32.120A Nondisplaced Zone II fracture of sacrum, initial encounter for closed fracture

S32.121A Minimally displaced Zone II fracture of sacrum, initial encounter for closed

fracture

S32.122A Severely displaced Zone II fracture of sacrum, initial encounter for closed

fracture

S32.129A Unspecified Zone II fracture of sacrum, initial encounter for closed fracture

S32.130A Nondisplaced Zone III fracture of sacrum, initial encounter for closed

fracture

S32.131A Minimally displaced Zone III fracture of sacrum, initial encounter for closed

fracture

S32.132A Severely displaced Zone III fracture of sacrum, initial encounter for closed

fracture

S32.139A Unspecified Zone III fracture of sacrum, initial encounter for closed fracture

S32.14XA Type 1 fracture of sacrum, initial encounter for closed fracture




S32.19XA Other fracture of sacrum, initial encounter for closed fracture

S32.2XXA Fracture of coccyx, initial encounter for closed fracture






S32.2XXB Fracture of coccyx, initial encounter for closed fracture




S34.101A Unspecified injury to L1 level of lumbar spinal cord, initial encounter










S34.109A Unspecified injury to unspecified level of lumbar spinal cord, initial encounter




S34.111A Complete lesion of L1 level of lumbar spinal cord, initial encounter










































34










S34.119A Complete lesion of unspecified level of lumbar spinal cord, initial encounter

S34.119A Complete lesion of unspecified level of lumbar spinal cord, initial encounter

S34.121A Incomplete lesion of L1 level of lumbar spinal cord, initial encounter










S34.129A Incomplete lesion of unspecified level of lumbar spinal cord, initial encounter

S34.129A Incomplete lesion of unspecified level of lumbar spinal cord, initial encounter

S34.131A Complete lesion of sacral spinal cord, initial encounter

S34.131A Complete lesion of sacral spinal cord, initial encounter

S34.132A Incomplete lesion of sacral spinal cord, initial encounter

S34.132A Incomplete lesion of sacral spinal cord, initial encounter

S34.139A Unspecified injury to sacral spinal cord, initial encounter




S34.3XXA Injury of cauda equina, initial encounter




Z13.820 Encounter for screening for osteoporosis

Z78.0 Asymptomatic menopausal state

Z79.3 Long term (current) use of hormonal contraceptives

Z79.51 Long term (current) use of inhaled steroids

Z79.52 Long term (current) use of systemic steroids

Z79.891 Long term (current) use of opiate analgesic

Z79.899 Other long term (current) drug therapy

Z82.62 Family history of osteoporosis

Z87.310 Personal history of (healed) osteoporosis fracture

Z87.311 Personal history of (healed) other pathological fracture

Z90.721 Acquired absence of ovaries, unilateral

Z90.722 Acquired absence of ovaries, bilateral



































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35


Z90.79 Acquired absence of other genital organ(s)

HCPCS Level

II Description Comments

N/A
