M80.8B9A — Other osteoporosis with current pathological fracture, unspecified pelvis, initial encounter for fracture
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- If bone metastasis (C79.51 or C79.52) is treated, the medical record must also contain the diagnosis of the primary malignant neoplasm and be available on request.
- Medical records must include diagnostic information and lab results that support medical necessity, including documentation of specific signs and symptoms substantiating FDA labeled or off‑label use.
- The record should indicate the patient was advised to take adequate calcium and vitamin D supplementation.
- Diagnosis codes supporting medical necessity must be submitted on the claim, including breast cancer code plus bone loss code and a code documenting current adjuvant SERM or aromatase inhibitor therapy when applicable.
Key Coverage Criteria
- Intravenous bisphosphonate administration is covered for treatment of osteoporosis when medical record documents need for IV route, including description of treatment failure of oral or self‑administered osteoporosis drugs.
- Bisphosphonate therapy is covered for heterotopic ossification when the medical record documents clinical need for treatment and justifies IV administration.
- Bisphosphonate therapy is covered for bone metastasis (C79.51 or C79.52) provided the patient's record also contains a diagnosis of the primary malignant neoplasm.
- In breast cancer patients receiving adjuvant selective estrogen receptor modulators or aromatase inhibitor therapy, bisphosphonates are covered when billed with an appropriate breast cancer diagnosis code and a bone loss diagnosis code documenting treatment indication.
- Vitamin D assay testing is payable under Medicare Part B when performed in an office (POS 11), independent clinic (POS 49), Federally Qualified Health Center (POS 50), or independent laboratory (POS 81).
- Non-physician practitioners (e.g., nurse practitioners, clinical nurse specialists, physician assistants) may certify, order, and establish the plan of care for Vitamin D assay testing as authorized by State law (outpatient settings other than CORFs).
20 Active Policies
L39624 — Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
A57484 — Billing and Coding: Vitamin D Assay Testing
J05
A57604 — Billing and Coding: Intraoperative Neurophysiological Testing
J05
L34623 — Intraoperative Neurophysiological Testing
J05
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