Download Bone Loss Assessment Recommendations

Bone Loss Assessment Recommendations
Regardless of score patients should be considered for a bone loss test. Medicare and the
Osteoporosis Foundation recommend bone loss tests as a preventive measure, (even with patients
that are considered low risk). And urine tests, i.e. NTx, offer an easier, faster way to determine
whether bone loss is occurring. The following step guide will help determine the best course
of action based on age, risk profile, and as
NOTES…
recommended by Medicare and CPT billing
guidelines.
STEP 1: Bone Loss Assessment (completed by
patient in the waiting room, staff should include
copy in patient file) For billing, use CPT 99420 –
Administration and Interpretation of health risk
assessment questionnaire. A copy of the report
should be included with the recommendations.
Negative screens can be reviewed by staff person.
The additional questions included in this document
should be completed by doctor and patient during
visit. Both documents should be including in a
request for reimbursement. In order to be
reimbursed for the A/I code, Positive screens require
provider to review risk responses during visit.
STEP 2: Review Risk Responses with patient and
obtain HPI1 (history of present illness/symptoms) During patient interview. Any score of 1 or
more, should be considered for a bone density test and/or a NTx rate of bone loss test. NOTE: a
confirmed risk response on any weighted question(s), meet the minimum criteria for testing
according to Medicare reimbursement guidelines and the National Osteoporosis
Foundation (see questions 6, 82, 103, 11, 12).
During visit with patient, review risk responses highlighted on the PPES, and confirm risk status.
For example, if patient responds, “yes” to question 3, “physically inactive for prolonged periods
of time,” further qualify the statement by determining, timing, duration, severity, context,
modifying factors, or associated signs and symptoms, contributing to the inactivity. If yes on
question 8 or 10, determine if reason for response is early, or surgically induced menopause,
(before age 40). If so, patient meets minimum criteria for a BMD test. When you have reviewed
and confirmed risk responses from screen, ask and record responses to the following additional
1
Include completed Bone Loss Assessment with confirmed risk factors, with any additional questions
completed during visit to obtain PFSH for ensuing E/M work related to treatment and/or counseling to
prevent further bone loss.
2
Meets minimum criteria for BMD test if reason for yes response is early or surgically induced
menopause (under age 40)
3
Meets minimum criteria for BMD test if reason for yes response is early or surgically induced
menopause (under age 40)
medical history questions to obtain all pertinent information related to the history of present
illness/symptoms, before ordering labs/tests or developing a treatment plan.
ASK…
**1. Do you have any of the following: Type 1 diabetes? Liver disease? Kidney disease? Or
Thyroid disease?4
2. Have you ever taken oral contraceptives? If yes,
what was your age at first use? How long?
3. Any issues with depression? Either clinically
diagnosed or untreated?
4. History of eating disorder? Anorexia or bulimia?
Extreme or starvation dieting?
5. High protein diet?
6. Are you, or have you ever been lactose intolerant?
7. Any current or past diseases of the small intestine?
Colitis or Crohn’s?
8. For women with no children, ask, “Have you ever
been pregnant? If yes, move onto next question; if no,
then add as additional risk factor.
9. And for women with children, how old were you
when you had your first child? (Patients with a
teenage pregnancy should also be evaluated for bone
loss.)
10. Were you ever tested for bone loss or bone density
under the care of another physician?
NOTES…
**A confirmed yes response on question 1 meets minimum requirement for a BMD test.
.
A risk response on any of the subsequent questions 2-10 should be considered for test to
determine if bone loss is occurring and at what rate. Add risk factors from the Bone Loss screen,
and the items addressed during the visit, and evaluate to determine next steps.
BMD test or NTx tests? Bone Density versus Bone Loss
If patient is pre-menopausal, and has few risk factors (1 or 2), NTx is recommended because it
gives patient a faster response than a bone density test, and can determine whether bone loss is
occurring. However, if patient is menopausal, and has multiple risk factors, it is recommended
patient receive both tests. BMD gives patient a definitive answer as to the exact density, so that
the best course of treatment can be selected. Whereas, NTx will inform patient if bone loss is
occurring, and at what rate. NTx tests can helpful before menopause (as a litmus whether bone
loss is occurring) and after menopause, (if bone loss has been diagnosed, and a medication is
being used to prevent further loss that could result in osteoporosis). NTx tests are used in
tandem with treatment of bone loss to determine the efficacy of the selected medication.
4
Any one of these diseases meets minimum requirement for BMD test.
STEP 3: Order Diagnostic Labs/Tests (use the following key to help guide decision)
Pre-menopausal, + any non-weighted question: As a preventive measure, order NTx test to
determine if bone loss is occurring, and at what rate.
Pre-menopausal + any weighted question: Order both tests. Consider beginning some form of
abatement, through lifestyle modification and/or Rx. Use NTx to measure efficacy of
Treatment.
Menopausal + any non-weighted question(s): As a preventive measure, order NTx to determine
if bone loss is occurring, and at what rate. Discuss
NOTES…
reasons for test. Counsel re: lifestyle changes (if
applicable).
Menopausal + any weighted question(s): Order BMD.
Consider beginning prescription drug treatment.
Consider NTx to determine if treatment is efficacious.
According to Medicare Billing Recommendation, any
of the following conditions meet the minimum
requirement for testing:
Any woman over the age of 65
Or, younger women with one of the following
conditions should also be tested:
Postmenopausal and have at least one risk factor for
osteoporosis, including having fractured a bone (Yes on Question 10 plus one other risk factor)
A vertebral abnormality (yes on Question 12)
Take medications, such as prednisone (see Question 6)
Any of the following: Type 1 diabetes, liver disease, kidney disease, or thyroid disease
A family history of osteoporosis (see Question 11)
Experienced early menopause (see questions 8 and/or 10; must determine that “yes” response on
question 8 or 10 is due to early menopause, before age 40)
(For Information about types of tests and reimbursement guidelines, see below: LABS/TESTS
BONE DENSITY)
Labs/Tests Bone Density
Bone density is usually studied by using one of various types of diagnostic bone mass
measurement techniques that have been recognized by the FDA for that purpose. Bone density
can be measured at the wrist, spine, hip, or calcaneus (heel). Various single and combined
methods of measurement may be required to
diagnose bone disease, monitor the course of bone
NOTES…
changes with disease progression, or monitor the
course of bone changes with therapy.
If patient meets criteria for a bone density test, you may
use one of the following FDA approved diagnostic tests:
Urine tests: fasting calcium/creatinine, fasting
hydroxyproline/creatine (NTx)
Blood tests
Calcium/phosphorous: 1,25(OH)2Vitamin D3
Progesterone; Estrogens (estradiol, estrone)
Serum Gla-protein
Photon Absorptiometry: single, dual
Computed tomography
Is Bone Mass Testing Reimbursable?
Providers unclear on payment criteria may wish to use
Medicare criteria as a preliminary guide, however, private payers may use other criteria, and the
following guidelines should only be used as a general compass.
Medicare covers preventive tests for patients who meet the following criteria:
A “qualified individual” means a Medicare beneficiary who meets the medical indications for at
least one of the five categories listed below:
 A woman who has been determined by the physician or qualified non-physician
practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis,
based on her medical history5 and other findings;
 An individual with vertebral abnormalities, as demonstrated by an X-ray to be indicative
of osteoporosis, osteopenia (low bone mass), or vertebral fracture;
 An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy
equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than three
months;
5
Include completed Bone Loss Assessment with any additional questions included in this document, to satisfy
PFSH for any ensuing E/M work related to treatment and/or counseling to prevent further bone loss. See
suggestions for lifestyle modification specific to each area of risk
 An individual with known primary hyperparathyroidism; or
 An individual being monitored to assess the response to, or efficacy of, an FDA-approved
osteoporosis drug therapy.
In addition, all of the coverage criteria listed below must be met:
The individual’s physician or qualified non-physician practitioner treating the beneficiary must
provide an order, following an evaluation of the need for a bone mass measurement that includes
a determination as to the medically appropriate measurement to be used for the individual.
NOTE: A physician or qualified non-physician practitioner treating the beneficiary for the
purpose of the bone mass measurement benefit is one who provides a consultation or treats a
beneficiary for a specific medical problem, and who uses the results in the management of the
patient. For the purposes of the bone mass measurement benefit, qualified non-physician
practitioners include physician assistants, nurse practitioners, clinical nurse specialists, and
certified nurse midwives.
The service must be a radiologic or radioisotopic procedure (or other procedure) that meet the
following requirements:
Is performed with a bone densitometer (other than dual photon absorptiometry (DPA)) or a
bone sonometer (i.e., ultrasound) device approved or cleared for marketing by the FDA
Is performed for the purpose of identifying bone mass, detecting bone loss, or determining
bone quality; and
Includes a physician’s interpretation of the results of the procedure.
The service must be furnished by a qualified supplier or provider of such services under the
appropriate level of supervision by a physician.
The service must be reasonable and necessary for diagnosing, treating, or monitoring an
individual as defined above.
Medicare provides coverage of a bone mass measurement that meets the criteria as described
above once every 2 years (i.e., at least 23 months have passed following the month in which the
last Medicare-covered bone mass measurement was performed).
NOTE: If medically necessary, Medicare may provide coverage for a beneficiary more
frequently than every 2 years.
NTX versus BMD testing (bone loss can be measured by using NTX over shorter periods of
time, 60 to 90 days, while BMD is used to diagnose Osteoporosis (and is measured in 12 to 24
month increments)
Is NTx test reimbursable?
http://www.medscape.com/viewarticle/508542_4
The Centers for Medicare and Medicaid Services (CMS) has established a national policy for
reimbursement of collagen crosslink testing, as of November 25, 2002. The Medicare NCD for
urine based collagen crosslink tests (CPT 82523) lists three uses under 'Indications':
1. Identify individuals with elevated bone resorption, who have osteoporosis in whom response
to treatment is being monitored;
2. Predict response (as assessed by bone mass measurements) to FDA approved anti-resorptive
therapy in postmenopausal women;
3. Assess response to treatment of patients with osteoporosis, Paget's disease of the bone, or risk
of osteoporosis where treatment may include FDA approved anti-resorptive agents, antiestrogens or selective estrogen receptor moderators.
STEP 4: Diagnosis/Treatment Support
With a completed bone density test, use the chart below to determine the proper diagnosis. This
will also help determine whether more rigorous treatment is indicated. As a general rule,
Hormone Treatment is more effective with perimenopausal, menopausal and post
menopausal patients experiencing mild to moderate bone loss, whereas, bophosphonates
and SERMs tend to be more effective in treating severe bone loss, and/or patients
diagnosed with osteoporisis.
World Health Organization standards for the diagnosis
of Osteoporosis:
NOTES…
1.0 SD (Standard Deviation) = Normal Bone Mass
1.0 SD to -1.0 SD = Mild or Borderline Osteopenia
-1.0 SD to -2.5 SD = Low Bone Mass or Moderate
Osteopenia
-2.5 SD or Lower = Osteoporosis.
In 2008, the American College of Physicians made these
new recommendations:
 Doctors should prescribe medication to people
who have known osteoporosis and people who
have experienced a fragility fracture (when a
bone breaks without significant trauma)
 Doctors should consider preventive treatment for
patients at risk of getting osteoporosis
 Doctors should take into account a patient's individual risk and benefits when selecting
among drug treatment options for osteoporosis
For mild bone loss or as a preventive measure, adjustments in lifestyle should be considered for
first course of treatment. Several questions in the Bone Loss Screen (1-5) address lifestyle
choices that can be addressed during visit. If patient is at increased risk due to a “yes” response
on a lifestyle question, inform patient that changes in behavior, even seemingly minor changes
now, can have a profound effect on her general health later in life.
Included in this document are recommendations specific to each risk response, and offer
counseling suggestions that will help encourage patients to make changes in their behavior or
lifestyle choices. Remind patient that the appropriate amount of calcium can help mitigate some
risk factors, but it should not be perceived as a panacea.
For low, moderate or severe rates of bone loss in pre-menopausal patients, medication should be
considered (in addition to lifestyle adjustments) as a preventive measure to decrease the rate of
bone loss. Individuals with bone loss at earlier stages in their life should be considered for
alternative therapies e.g. low-dose bioidentical HRT. NTx tests can measure the efficacy of the
selected treatment and can be administered at 60 to 90 day intervals, so that patient and provider
are able to try different methods until they discover the most effective method for managing
bone loss.
For low, moderate, or severe rates of bone loss in perimenopausal or menopausal women (who
are managing their symptoms with a hormone replacement therapy) should consider modifying
or changing medications. She may also consider adding a medication as there are new drugs
being used to treat bone loss and osteoporosis. Ideally suited for individualized therapy, because
for various reason, they may be adversely affected by their current HRT.
Recommend changes that can be made versus changes that cannot. While it’s important to point
out genetic risk factors e.g. ethnicity or family history, time should not be used discussing them;
instead, use that time to counsel patient on mitigating behaviors like cutting down on alcohol,
and monitoring daily calcium intake.
Treatment Options for Bone Loss, Osteopenia and Osteoporosis
Hormone therapy: Hormone Replacement Therapy (synthetic) or Bioidentical Hormone
Therapy. HRT can be effective at slowing bone loss in menopausal women. Alternative forms
of hormone therapy include patches, creams and the vaginal ring (see chart below for
suggestions).
Synthetic and Bioidentical Estrogen Preparations Available in the United States
ESTROGENS
BRANDS
Bioidentical
17-beta estradiol (E2)
Estrone sulfate (E1)
Alora®, Climara®, Estraderm®, Fempatch®, Oesclim®,
Vivelle® (all E2 patches); Combi Patch® (E2 +
norethindrone); Emcyt® (capsule); Estrace® (vaginal
cream and tablet); Femring® and Estring® (vaginal
rings); Estrasorb® and Estragel® (transdermal
preparations); and available generically in troches,
sublingual drops, suppositories, creams, gels, or
capsules from compounding pharmacies.
Available generically in troches, sublingual drops,
suppositories, creams, gels, or capsules from
compounding pharmacies.
Estropipate (E1)
Estriol (E3)
Ogen® (tablet and vaginal cream); Ortho-Est® (tablet);
generic tablet
Available generically in troches, sublingual drops,
suppositories, creams, gels, or capsules from
compounding pharmacies.
Non Bioidentical (Synthetic)
Ethinyl estradiol
Esterified estrogens®
Conjugated equine estrogens
(CEE)
Dienestrol
PROGESTOGEN/PROGESTERONE
Brevicon®, Demulen®, Levlen®, Lo-Ovral®, Loestrin®,
Modicon®, Nordette®, Norinyl®, Ortho-Cept®, OrthoCyclen®, Ortho-Novum®, Ortho-Tri-Cyclen®, Ovcon®,
Tri-Levlen®, Tri-Norinyl®, Triphasil®, Nelova® (all
tablets in combination with synthetic progestins);
Estinyl® and Feminone® (tablet)
Estratab® (tablet, vaginal cream); PremPro® (tablet in
combination with MPA); PremPhase® (tablet in
combination with MPA); generic (tablet)
Premarin® (tablet, vaginal cream); PremPro® (tablet in
combination with MPA); generic (tablet)
Ortho Dienestrol Cream® (vaginal cream)
BRAND NAME
Bioidentical (Progesterone)
Progesterone (P4)
Non-Bioidentical (Progestogen)
Medroxyprogesterone acetate
(MPA)
Crinone® and Utrogestan® (vaginal gels); Pro-Gest®
and other brands (transdermal cream); Prometrium®
(capsule); and available generically in troches,
sublingual drops, suppositories, creams, gels, or
capsules from compounding pharmacies.
Provera®, Amen®, Curretab®, and Cycrin® (tablet);
PremPro® and PremPhase® (tablet in combination with
CEE)
Norethindrone acetate
Aygestin®, Micronor®, Norlutate®, Nor-QD® (tablet)
Norgestrel
Norgestimate
Ovrette® (tablet)
Levo-Norgestrel
Desogestrel
Preven® (tablet in combination with EE)
Megestrol acetate
Megace® (tablet)
Ortho-Tri-Cyclen® (tablet in combination with EE)
Desogen® (tablet)
With more severe bone loss in menopausal and post-menopausal patients, and a diagnosis of
osteopenia or osteoporosis using WHO standards, there are additional drugs that may be more
effective at reversing the rate of bone loss, including the following:
If HT is unsuccessful or patient requests an alternative approach, and lifestyle changes don't help
control osteoporosis, the following drugs can help slow bone loss and may even increase bone
density over time:
Bisphosphonates: Much like estrogen, this group of drugs can inhibit bone breakdown, preserve
bone mass, and even increase bone density in spine and hip, reducing the risk of fractures.
Raloxifene (Evista). This medication belongs to a class of drugs called selective estrogen
receptor modulators (SERMs). Raloxifene mimics estrogen's beneficial effects on bone density
in postmenopausal women, without some of the risks associated with estrogen, such as increased
risk of uterine cancer and, possibly, breast cancer.
Calcitonin. A hormone produced by the thyroid gland, calcitonin reduces bone resorption and
may slow bone loss. It may also prevent spine fractures, and may even provide some pain relief
from compression fractures. Because calcitonin isn't as potent as bisphosphonates, it's normally
reserved for people who can't take other drugs.
Teriparatide (Forteo). This powerful drug, an analog of parathyroid hormone, treats
osteoporosis in postmenopausal women and men who are at high risk of fractures. Unlike other
available therapies for osteoporosis, it works by stimulating new bone growth, as opposed to
preventing further bone loss. Teriparatide is given once a day by injection under the skin on the
thigh or abdomen.
Tamoxifen. This synthetic hormone is used to treat breast cancer and is given to certain highrisk women to help reduce their chances of developing breast cancer. Although tamoxifen blocks
estrogen's effect on breast tissue, it has an estrogen-like effect on other cells, including bone
cells. As a result, tamoxifen appears to reduce the risk of fractures, especially in women older
than 50.
Emerging therapies: A new physical therapy program has been shown to significantly reduce
back pain, improve posture and reduce the risk of falls in women with osteoporosis who also
have curvature of the spine. The program combines the use of a device called a spinal weighted
kypho-orthosis (WKO) — a harness with a light weight attached — and specific back extension
exercises. The WKO is worn daily for 30 minutes in the morning and 30 minutes in the afternoon
and while performing 10 repetitions of back extension exercises.
Sources:
AAFP (American Academy of Family Physicians)
http://www.nlm.nih.gov/medlineplus/osteoporosis.html
ACOG (American Academy of Obstetricians and Gynecologists)
http://www.iofbonehealth.org/patients-public/about-osteoporosis/prevention/exercise.html
Step 5: Counseling Support
The following recommendations are specific to each risk response from the screen. Use in
conjunction with any preventive measures/medications, or treatment measures (with patients
who are diagnosed with bone loss and/or osteoporosis). If bone loss is tested and the results are
negative for bone loss, preventive measures are suggested for any patients entering menopause or
receiving treatment for menopausal symptoms, as they are at greater risk for developing bone
loss in the near future.
Remind patient that even minor changes in lifestyles choices can have profound impact on
overall health, and can abate or reverse the rate of bone loss.
Use the following for counseling support, in tandem with any treatment or preventive
measures (including test results and Rx management). Document by initialing item and
include a copy of all reviewed items in patient records and the request for reimbursement.