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ABOUT
BONE DENSITOMETRY
Introduction
Different Techniques
Dexa or Ultrasound?
BONE
DENSITOMETRY EQUIPMENT
Types of Equipment
New or Preowned?
Operator Requirements
BONE
DENSITOMETRY PRACTICE
Why offer Bone Densitometry?
Indications for Bone Densitometry
Patient Reimbursements
Favorable Legislation
ABOUT
OSTEOPOROSIS
Basic Facts
Not Just a Woman's Disease
Prevention & Treatment
Links
INTEGRITY'S
B D EQUIPMENT PROGRAM
Why Bone Densitometry is Important
Now
How IMS Can Help
TERMS OF USE
© 2004, Integrity Medical Systems, Inc. |
Why Offer Bone Densitometry?
The physicians offering bone
densitometry range from medical specialists such as gynecologists,
radiologists, rheumatologists, and clinical endocrinologists,
to primary care physicians, hospital outpatient departments
and independent laboratory and screening facilities.
Consider, for example, the added benefits of bone densitometry to women's health
clinics. Women remain the primary drivers of health care, and services that
result in positive experiences are what keeps them coming back to your practice
or clinic. Today's female patient is typically an educated, empowered consumer
with a high level of participation in the healthcare of herself and her family.
Squeezing in a doctor's visit for annual preventive care isn't easy, but this
healthcare consumer will make the effort, provided the services and information
she receives are worth the time and money spent.
The practitioner will respond to women's
demands for streamlined, diversified services by adding bone densitometry
for osteoporosis screening in addition to mammography and breast health.
As these screenings increase, and as the empowered healthcare consumer
is retained by the practice or clinic over the course of a longterm
relationship, the opportunities for additional diagnostic or therapeutic
interventions will increase, which will increase patient volume. Simultaneously,
the practice or clinic enhances the quality of care and positions itself
as a women's health care site of choice in the community.
For the majority of women's clinics introducing
bone densitometry, most of the business comes from mammography screenings.
The savvy practitioner realizes that the mammo and osteoporosis screenings
share the same patient population. Every mammography patient you have
will eventually be forced to visit another practitioner for bone densitometry
screening if you do not offer it to them now. If you offer osteoporosis
screening to your mammo clients, within six months your bone density
screening could increase by as much as 95%, and could possibly add
a five-figure annual gross revenue boost - all without adding to expenditures
for salaried employees. Often, bone densitometry can be added without
hiring new staff at all. Existing staff, such as RT's, nurses and mammographers
can often be trained on to do bone density screenings.
Once you've added bone densitometry to your
practice or clinic, there are favorable conditions for insurance and
Medicare reimbursement.
The July 1998 provision of the Health Care Financing Administration mandating
Medicare reimbursement of bone mass measurement extends coverage beyond strictly
physician- ordered testing. Coverage is available if the scan is ordered by
a physician treating a patient . It is also available to "qualified non physician
practitioners" such as physician assistants, nurse practitioners, clinical
nurse specialists, and nurse-midwives.
There are over 1500 DEXA densitometers in
use in the U.S. Reimbursement for DEXA studies is paid by Medicare
in all 50 states and the District of Columbia and insurance companies
under CPT code 76076. HCFA/Medicare 1996 reimbursement was 3.58 RVU
or approximately $125 per study. Due to the large number of third party
payers in each state, and the numerous policy permutations, comprehensive
current information on DEXA reimbursement by these insurers is not
available at this time. However, private insurance reimbursements range
from $125 to $200. Average patient throughput time for 2 sites (AP
Spine and Femur) is 10 minutes. Actual scan time is 3 minutes. Break-even
operation of a densitometer can be achieved with as few as three patients
per week.
Pharmeceutical companies such as Merck, Sandoz, and Wyeth-Ayerst are actively
stimulating the osteoporosis diagnostic market in support of new osteoporosis
therapies. These companies will often provide marketing assistance to practitioners
and health care organizations to build referral patterns and increase patient
utilization. Also, the increasing number of clinical trials requires more investigators,
and presents additional revenue sources for practitioners offering bone densitometry.
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Indications for Bone Densitometry
1. Premenopausal women
with high risks (to evaluate the efficacy of treatment program for
that individual). Such risks include: Surgical menopause; Hypomenorrhea
or amenorrhea (especially associated with extensive exercise); Anorexia
nervosa
2. Males with one or more major risk factors: Hypogonadal
(low pooled testosterone); Ethanol abuse; Osteoporosis on radiograph;
Fracture with minor trauma
3. Prolonged immobilization (more than one month)
4. High suspicion of poor calcium intake for more
than ten years in select individuals: Hypercalciuria with or without
kidney stones (24 hour 4 mg/kg/day); Gastrointestinal diseases such
as malabsorption and hemigastrectomy (ten years after surgery)
5. Rheumatoid arthritis or ankylosing spondylitis
with continuous disease over a five-year duration.
6. When a patient begins chronic corticosteriod medication
or methotrexate and every one or two years while on these drugs.
7. Use of anticonvulsant therapy with Dilantin or
phenobarbital over a five-year duration.
8. Kidney disease with a creatinine clearance of less
than 50 ml/min or renal tubal disorders.
9. Evidence of osteomalacia such as low serum calcium,
low serum phosphorus and/or elevated alkaline phosphate.
10. Evidence of hyperparathyroidism with elevated
calcium, low phosporus, and/or elevated parathyroid hormone (especially
in mild or non-surgical cases to assess the efficacy of therapy).
11. Prolonged use of thyroid replacement (over ten
years).
12. Evaluation and monitoring of treatment program
for osteoporosis.
*Estrogen or estrogen/progesterone
*Testosterone replacement
*Calcitonin therapy
*Pharmacological amounts of vitamin D with calcium in patients on chronic corticosteroids
or patients with advanced osteoporosis or osteomalacia
*Diphosphonate therapy
*Fluoride therapy (Note: Only diphosphonate and fluoride are experimental)
*Anabolic steriod therapy
13.Individual consideration with a letter of explanation regarding
the procedure (e.g. insulin dependent diabetes).
14. Postmenopausal women with two or more major risk
factors (single measurement for the absolute amount of bone and not
rate of bone loss is helpful to determine the need for therapy).
*Positive family history
*Height under 5 feet 3 inches
*Loss of height of over one inch
*Lifelong low calcium intake (milk intolerant or avoids all dairy products)
*Previous fracture in adult years with minimal trauma or in classic fracture
sites due to osteoporosis (e.g. vertebrae, wrist, hip, pelvis)
*Evidence of osteopenia on plain radiograph
*Age of 65
*Ethanol abuse
"Laboratory studies are not diagnostic for primary
osteoporosis, but are important in determining the cause of decreased bone
mineral density and in monitoring therapy. Evaluation should include CBC, ESR,
urinalysis, chemistry profile, thyroid function, serum protein determinations,
and 24-hour urine calcium. Occasionally, measures of vitamin D metabollites,
parathyroid hormone, ionized calcium, serum fluoried, FSH and estradiol, urine
protein electrophoresis, and serum and urine immuno-electrophoresis may be
necessary. Roentgenograms of appropriate areas of the skeleton are indicated,
and photon beam absorpitometry (especially the dual-beam method) is an effective
method to measure bone mineral density in the spine, hip, wrist, and knee,
and in other sites. Rarely, isotopic bone scan, parathyroid ultrasound, quantitative
CT scanniing of the spine, and iliac crest biopsy with tetracycline labeling
may be needed."
_ from Guidelines for Reviewers of Rheumatic Disease Care. January 1986 Council
on Rheumatological Care of the American Rheumatism Association
Favorable Legislation
Fortunately, due to the 1997 passage of
landmark legislation, the Bone Mass Measurement Act, there is a national
Medicare coverage policy for BMD testing in all elgible patients. The
National Osteoporosis Foundation guidelines recommend BMD testing in
all women over 65 years of age and postmenopausal women under age 65
with one additional risk factor. All approved BMD testing techniques
are good predictors of future risk of fracture.
Considering the billions of dollars spent on hospital and nursing home costs
incurred by osteporotic fractures (slightly under $14 billion in 1995) increased
levels of bone mass measurement reimbursement is clearly good government. The
costs of treating osteoporosis outstrip those of either congestive heart failure
or asthma. Through early detection of osteoporosis made possible only by bone
density screening, the ravaging effects of the disease may be reduced considerably.
Bone mass measurement is a component of care in all postmenopausal women, especially
those over the age of 65.
Health care legislation continues to be proposed. As of July 1, 1998, Congress
enacted favorable provisions for implementation of medicare coverage of and
payment for bone mass measurements approved in 1997. Prior to implementation
of the July 1998 provisions, bone densitometry reimbursement policy was a hodgepodge
of limitations imposed by state Medicare Medical Directors. Specifically, the
1998 laws ordered reimbursements for bone density screening even when the patient
tested negative for osteoporosis, allowing practitioners to take a preventive
approach to osteoporosis designed to avoid expensive surgeries, hosptalizations
and nursing home admissions.
According to the Health Care Financing Administration of the Department of
Health and Human Services, bone mass measurements using bone densitometers
and sonometers are considered to be the most valuable objective indicator of
the risk of fracture and/or osteoporosis. Government approval of the clinical
use of these devices is based on the assumption that bone mass is an important
determinant of osteoporotic fractures, and that bone mass measurements may
help reduce the number of fractures by identifying high- risk individuals,
who can then receive appropriate preventive measures. Because osteoporosis
is generally considered preventable, but not reversible, the Health Care Financing
Administration believes that early detection of at-risk individuals is a desirable
health outcome.
The law defines a "bone mass measurement" to
mean
(1) a radiologic, radioisotopic, or other procedure approved by the Food and
Drug Administration (FDA) for the purpose of identifying bone mass, detecting
bone loss, or interpreting bone quality, and
(2) it includes a physician's interpretation of the results of those bone mass
measurement procedures. The law also authorizes Medicare coverage of those
medically necessary approved measurements that are performed for a "qualified
individual" that fall into at least one of five diagnostic categories. These
include
(1) an estrogen-deficient woman at clinical risk for
osteoporosis,
(2) an individual with vertebral abnormalities,
(3) an individual receiving long-term glucocorticoid
(steroid) therapy,
(4) an individual with primary hyperparathyroidism,
and
(5) an individual being monitored to assess the response
to, or efficacy of, an approved osteoporosis drug therapy.
The Medicare Osteoporosis Measurement Act
of 2001 proposes to extend the five guidelines for qualified individuals
to include men. Specifically, the first guideline would be changed
to read, "an individual, including an estrogen-deficient woman, at
clinical risk for osteoporosis." This change of just a few words will
vastly increase the opportunities for men and women to receive bone
mass measurement before experiencing a fracture. Unfortunately, all
too many patients never find out that they have low bone mass density
until they are in an advanced osteoporotic condition (i.e., osteoporosis
with a fracture event).
Patient Reimbursement
Under the July 1998 Medicare provisions,
Medicare payments for covered bone mass measurements will be paid for
under the physician fee schedule (42 CFR part 414) as required by statute.
This provision revised the definition of "physician services" in Sec.
414.2 to include bone mass measurements. When bone mass measurement
procedures are furnished to hospital inpatients and outpatients, the
technical components of the procedures are payable under existing payment
methods for hospital services. These methods include payments under
the prospective payment system, on a reasonable cost basis, or under
a special provision for determining pay rates for hospital outpatient
radiology services.
The codes listed below are payable under this benefit:
76075 - Dual energy x-ray absorptiometry (DEXA), bone density
study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)
76076 - Dual energy x-ray absorptiometry (DEXA), bone
density study, one or more sites; appendicular skeleton (peripheral)
(e.g., radius, wrist, heel)
76078 - Radiographic absorptiometry (photodensitometry),
one or more sites
78350 - Bone density (bone mineral content) study,
one or more sites; single photon absorptiometry
G0130 - Single energy x-ray (SEXA) absorptiometry
bone density study, one or more sites, appendicular skeleton (peripheral)
(e.g., radius, wrist, heel)
G0131 - Computerized tomography bone mineral density
study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)
G0132 - Computerized tomography bone mineral density
study, one or more sites; appendicular skeleton (peripheral) (e.g.,
radius, wrist, heel)
G0133 - Ultrasound bone mineral density study, one
or more sites, appendicular skeleton (peripheral) (e.g., radius, wrist,
heel)
Frequency of Bone Densitometry
Tests
The Health Care Financing Administration
has established the following frequency standards for coverage
of bone mass measurements:
In general, coverage for follow-up bone mass measurements will be limited to
only one measurement every 2 years for beneficiaries who receive coverage of
bone mass measurements.
Follow-up bone mass measurements performed more frequently than once every
2 years may be covered when medically necessary. Examples of situations where
more frequent bone mass measurements procedures may be medically necessary
include, but are not limited to, the following medical circumstances:
(1) Monitoring beneficiaries on long-term glucocorticoid (steroid)
therapy of more than 3 months; and
(2) allowing for a confirmatory baseline bone mass
measurement (either central or peripheral) to permit monitoring of
beneficiaries in the future if the initial test was performed with
a technique that is different from the proposed monitoring method,
(for example, if the initial test was performed using bone sonometry
and monitoring is anticipated using bone densitometry, we will allow
coverage of baseline measurement using bone densitometry.
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