M85.811 — Other specified disorders of bone density and structure, right shoulder
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- All documentation must be maintained in the patient medical record and made available to the contractor upon request, with every page legible and including patient identification (complete name, dates of service).
- The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- Results of the vitamin D testing and the resulting treatment regimen must be documented in the patient's medical record, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures (e.g., progress notes and written laboratory reports).
Key Coverage Criteria
- 25-hydroxy vitamin D testing (including fractions, if performed) is covered when deemed reasonable and necessary per Local Coverage Determination L33771.
- 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).
20 Active Policies
A59561 — Billing and Coding: Bisphosphonate Drug Therapy
J05
L39624 — Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
A56907 — Billing and Coding: Bisphosphonate Drug Therapy
J05
A57484 — Billing and Coding: Vitamin D Assay Testing
J05
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