Coding and Reimbursement

Category III CPT® Codes† for BCT and BCT with concurrent VFA:

coding

In typical use, retrieval and transmission of the scan data to a centralized testing lab (0555T) is performed by a Radiology department or imaging facility; assessment of bone strength and fracture risk and bone mineral density (0556T) is performed by the centralized testing facility at O.N. Diagnostics; and interpretation and report (0557T) is performed by a physician with expertise in osteoporosis and BCT. Such a physician would typically be the same type of physician who has the medical expertise to interpret results from DXA testing. For BCT with concurrent VFA, a single code (0743T) is used for all steps and modifiers can be used for only the technical ("-TC") and professional ("-26") components. VFA is not available as a stand-alone test. For situations in which either BCT or BCT with concurrent VFA is medically indicated and a patient does not have a previous CT scan that can be utilized for the test, a CT scan can be ordered (0558T) solely for the purposes of an accompanying BCT.

Reimbursement & Payment
For diagnostic purposes, BCT is nationally covered by Medicare as a Bone Mass Measurement test, with waiver of copayment and deductible. Patients in traditional (“Part B”) Medicare must meet certain criteria for coverage. In addition to meeting those criteria, Medicare will typically only cover one Bone Mass Measurement test (whether DXA, BCT, CT, or ultrasound) once every two years; in special circumstances, additional testing within two years might be covered if considered medically necessary.

BCT with concurrent VFA is reimbursable by traditional Medicare if considered medically necessary, but not under the Bone Mass Measurement benefit; waiver of copayment and deductible does not apply.

Because BCT is nationally covered by Medicare as a Bone Mass Measurement test, Medical Advantage plans should also cover BCT, although the waiver of copayment and deductible may depend on the patient’s plan. For Bone Mass Measurement tests, most Medical Advantage plans have the same coverage criteria as those for traditional Medicare. For private insurance beyond Medicare plans, coverage for BCT varies; check your plan.

At present, the O.N. Diagnostics IDTF only accepts insurance from traditional Medicare (“Part B”); all other patients must self-pay. Patients who self-pay may still submit their own reimbursement claim to their plan and can include their itemized bill from O.N. Diagnostics. For information on self-pay rates, refer to the Frequently Asked Questions.

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