LCD Reference Article Billing and Coding Article

Billing and Coding: Bisphosphonate Drug Therapy

A56907

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Source Article ID
N/A
Article ID
A56907
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Bisphosphonate Drug Therapy
Article Type
Billing and Coding
Original Effective Date
08/29/2019
Revision Effective Date
02/11/2024
Revision Ending Date
N/A
Retirement Date
N/A
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CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

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Article Guidance

Article Text

The billing and coding information in this article is dependent on the coverage indications, limitations, and/or medical necessity described in the related LCD, L34648 Bisphosphonate Drug Therapy.

Documentation Requirements
Note: If bone metastasis (C79.51 or C79.52) is the condition being treated, the diagnosis of a primary malignant neoplasm must be present in the patient’s medical record and available if requested.

Information in the medical record including diagnostic information and lab results should support the medical necessity of this service. Based on the indications listed, the specific signs and symptoms must be documented to substantiate the FDA labeled or the FDA off labeled reasons for drug usage. An indication that the patient has been advised to take adequate calcium and vitamin D supplementation should be in the medical record. The medical record must be available on request. Diagnosis codes supporting medical necessity should be submitted on the claim.

Evidence in the medical record should clearly support the need for the intravenous administration of bisphosphonates for the treatment of osteoporosis including description of treatment failure of oral or self-administered drugs for osteoporosis and heterotrophic ossification. Lab work should include serum creatinine measured prior to the administration of the drug.

Utilization Guidelines
It is expected that these services would be performed as indicated by current literature and/or standards of practice and should follow the guidelines for administration and safety found in the FDA approved labels for these drugs along with the indications found in the Coverage Indications, Limitations, and/or Medical Necessity section of this policy. When services are performed in excess of established parameters, it may result in medical review to determine if the services were medical necessity.

Preventive services other than those payable by statute are excluded from Medicare coverage.

Per the Summary and Analysis of Evidence contained in the associated LCD, the breast cancer diagnosis codes included in this Billing and Coding Article will reflect the current NCCN recommendations. It will continue to be required to bill the appropriate breast cancer diagnosis code, along with a bone loss diagnosis code, and a diagnosis code to reflect that the patient is currently receiving adjuvant selective estrogen receptor modulators OR aromatase inhibitor therapy for breast cancer.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(3 Codes)
Group 1 Paragraph

Intravenous administration by infusion should be billed with procedure code 96365 for first hour and procedure code 96366 for each additional hour. If the administration is by IV push, use procedure code 96374.

Group 1 Codes
Code Description
J1740 INJECTION, IBANDRONATE SODIUM, 1 MG
J2430 INJECTION, PAMIDRONATE DISODIUM, PER 30 MG
J3489 INJECTION, ZOLEDRONIC ACID, 1 MG
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(220 Codes)
Group 1 Paragraph

Note: Diagnosis codes must be coded to the highest level of specificity.

J3489 Zoledronic acid

To report low bone mass for procedure code J3489 use diagnosis code M81.0 - Age-related osteoporosis without current pathological fracture. For codes in the table below that require a 7th character, letter A initial encounter for fracture, D subsequent encounter for fracture with routine healing, G subsequent encounter for fracture with delayed healing, K for subsequent encounter for fracture with nonunion, P for subsequent encounter for fracture with malunion, or S sequela may be used.

For C79.51, C79.52, see Documentation Requirements L34648 Biphosphonate Drug Therapy.

For M85.80, M85.811, M85.812, M85.821, M85.822, M85.831, M85.832, M85.841, M85.842, M85.851, M85.852, M85.861, M85.862, M85.871, M85.872, M89.9 or M94.9, additional codes C50.011-C50.922 OR Z85.3, and Z79.810 OR Z79.811 must also be reported when the drug is used for treatment of bone loss in women or men receiving adjuvant selective estrogen receptor modulators OR aromatase inhibitor therapy for breast cancer.

For M85.80, M85.811, M85.812, M85.821, M85.822, M85.831, M85.832, M85.841, M85.842, M85.851, M85.852, M85.861, M85.862, M85.871, M85.872, M89.9 or M94.9, additional codes C61 OR Z85.46 and Z79.899 must also be reported when the drug is used for treatment of bone loss in men receiving androgen deprivation therapy for prostate cancer.

When billing for osteopenia, ICD-10 codes M85.80, M85.811, M85.812, M85.821, M85.822, M85.831, M85.832, M85.841, M85.842, M85.851, M85.852, M85.861, M85.862, M85.871, M85.872, M89.9, or M94.9 should be used.

Group 1 Codes
Code Description
C50.011 Malignant neoplasm of nipple and areola, right female breast
C50.012 Malignant neoplasm of nipple and areola, left female breast
C50.021 Malignant neoplasm of nipple and areola, right male breast
C50.022 Malignant neoplasm of nipple and areola, left male breast
C50.111 Malignant neoplasm of central portion of right female breast
C50.112 Malignant neoplasm of central portion of left female breast
C50.121 Malignant neoplasm of central portion of right male breast
C50.122 Malignant neoplasm of central portion of left male breast
C50.211 Malignant neoplasm of upper-inner quadrant of right female breast
C50.212 Malignant neoplasm of upper-inner quadrant of left female breast
C50.221 Malignant neoplasm of upper-inner quadrant of right male breast
C50.222 Malignant neoplasm of upper-inner quadrant of left male breast
C50.311 Malignant neoplasm of lower-inner quadrant of right female breast
C50.312 Malignant neoplasm of lower-inner quadrant of left female breast
C50.321 Malignant neoplasm of lower-inner quadrant of right male breast
C50.322 Malignant neoplasm of lower-inner quadrant of left male breast
C50.411 Malignant neoplasm of upper-outer quadrant of right female breast
C50.412 Malignant neoplasm of upper-outer quadrant of left female breast
C50.421 Malignant neoplasm of upper-outer quadrant of right male breast
C50.422 Malignant neoplasm of upper-outer quadrant of left male breast
C50.511 Malignant neoplasm of lower-outer quadrant of right female breast
C50.512 Malignant neoplasm of lower-outer quadrant of left female breast
C50.521 Malignant neoplasm of lower-outer quadrant of right male breast
C50.522 Malignant neoplasm of lower-outer quadrant of left male breast
C50.611 Malignant neoplasm of axillary tail of right female breast
C50.612 Malignant neoplasm of axillary tail of left female breast
C50.621 Malignant neoplasm of axillary tail of right male breast
C50.622 Malignant neoplasm of axillary tail of left male breast
C50.811 Malignant neoplasm of overlapping sites of right female breast
C50.812 Malignant neoplasm of overlapping sites of left female breast
C50.821 Malignant neoplasm of overlapping sites of right male breast
C50.822 Malignant neoplasm of overlapping sites of left male breast
C50.911 Malignant neoplasm of unspecified site of right female breast
C50.912 Malignant neoplasm of unspecified site of left female breast
C50.921 Malignant neoplasm of unspecified site of right male breast
C50.922 Malignant neoplasm of unspecified site of left male breast
C61 Malignant neoplasm of prostate
C79.51 Secondary malignant neoplasm of bone
C79.52 Secondary malignant neoplasm of bone marrow
C90.00 Multiple myeloma not having achieved remission
C90.01 Multiple myeloma in remission
C90.02 Multiple myeloma in relapse
D05.11 Intraductal carcinoma in situ of right breast
D05.12 Intraductal carcinoma in situ of left breast
D05.81 Other specified type of carcinoma in situ of right breast
D05.82 Other specified type of carcinoma in situ of left breast
D05.91 Unspecified type of carcinoma in situ of right breast
D05.92 Unspecified type of carcinoma in situ of left breast
E83.52 Hypercalcemia
M61.011 Myositis ossificans traumatica, right shoulder
M61.012 Myositis ossificans traumatica, left shoulder
M61.021 Myositis ossificans traumatica, right upper arm
M61.022 Myositis ossificans traumatica, left upper arm
M61.031 Myositis ossificans traumatica, right forearm
M61.032 Myositis ossificans traumatica, left forearm
M61.041 Myositis ossificans traumatica, right hand
M61.042 Myositis ossificans traumatica, left hand
M61.051 Myositis ossificans traumatica, right thigh
M61.052 Myositis ossificans traumatica, left thigh
M61.061 Myositis ossificans traumatica, right lower leg
M61.062 Myositis ossificans traumatica, left lower leg
M61.071 Myositis ossificans traumatica, right ankle and foot
M61.072 Myositis ossificans traumatica, left ankle and foot
M61.08 Myositis ossificans traumatica, other site
M61.09 Myositis ossificans traumatica, multiple sites
M61.111 Myositis ossificans progressiva, right shoulder
M61.112 Myositis ossificans progressiva, left shoulder
M61.121 Myositis ossificans progressiva, right upper arm
M61.122 Myositis ossificans progressiva, left upper arm
M61.131 Myositis ossificans progressiva, right forearm
M61.132 Myositis ossificans progressiva, left forearm
M61.141 Myositis ossificans progressiva, right hand
M61.142 Myositis ossificans progressiva, left hand
M61.144 Myositis ossificans progressiva, right finger(s)
M61.145 Myositis ossificans progressiva, left finger(s)
M61.151 Myositis ossificans progressiva, right thigh
M61.152 Myositis ossificans progressiva, left thigh
M61.161 Myositis ossificans progressiva, right lower leg
M61.162 Myositis ossificans progressiva, left lower leg
M61.171 Myositis ossificans progressiva, right ankle
M61.172 Myositis ossificans progressiva, left ankle
M61.174 Myositis ossificans progressiva, right foot
M61.175 Myositis ossificans progressiva, left foot
M61.177 Myositis ossificans progressiva, right toe(s)
M61.178 Myositis ossificans progressiva, left toe(s)
M61.18 Myositis ossificans progressiva, other site
M61.19 Myositis ossificans progressiva, multiple sites
M61.211 Paralytic calcification and ossification of muscle, right shoulder
M61.212 Paralytic calcification and ossification of muscle, left shoulder
M61.221 Paralytic calcification and ossification of muscle, right upper arm
M61.222 Paralytic calcification and ossification of muscle, left upper arm
M61.231 Paralytic calcification and ossification of muscle, right forearm
M61.232 Paralytic calcification and ossification of muscle, left forearm
M61.241 Paralytic calcification and ossification of muscle, right hand
M61.242 Paralytic calcification and ossification of muscle, left hand
M61.251 Paralytic calcification and ossification of muscle, right thigh
M61.252 Paralytic calcification and ossification of muscle, left thigh
M61.261 Paralytic calcification and ossification of muscle, right lower leg
M61.262 Paralytic calcification and ossification of muscle, left lower leg
M61.271 Paralytic calcification and ossification of muscle, right ankle and foot
M61.272 Paralytic calcification and ossification of muscle, left ankle and foot
M61.28 Paralytic calcification and ossification of muscle, other site
M61.29 Paralytic calcification and ossification of muscle, multiple sites
M80.011A Age-related osteoporosis with current pathological fracture, right shoulder, initial encounter for fracture
M80.012A Age-related osteoporosis with current pathological fracture, left shoulder, initial encounter for fracture
M80.021A Age-related osteoporosis with current pathological fracture, right humerus, initial encounter for fracture
M80.022A Age-related osteoporosis with current pathological fracture, left humerus, initial encounter for fracture
M80.031A Age-related osteoporosis with current pathological fracture, right forearm, initial encounter for fracture
M80.032A Age-related osteoporosis with current pathological fracture, left forearm, initial encounter for fracture
M80.041A Age-related osteoporosis with current pathological fracture, right hand, initial encounter for fracture
M80.042A Age-related osteoporosis with current pathological fracture, left hand, initial encounter for fracture
M80.051A Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture
M80.052A Age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture
M80.061A Age-related osteoporosis with current pathological fracture, right lower leg, initial encounter for fracture
M80.062A Age-related osteoporosis with current pathological fracture, left lower leg, initial encounter for fracture
M80.071A Age-related osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture
M80.072A Age-related osteoporosis with current pathological fracture, left ankle and foot, initial encounter for fracture
M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M80.0B1A Age-related osteoporosis with current pathological fracture, right pelvis, initial encounter for fracture
M80.0B1D Age-related osteoporosis with current pathological fracture, right pelvis, subsequent encounter for fracture with routine healing
M80.0B1G Age-related osteoporosis with current pathological fracture, right pelvis, subsequent encounter for fracture with delayed healing
M80.0B1K Age-related osteoporosis with current pathological fracture, right pelvis, subsequent encounter for fracture with nonunion
M80.0B1P Age-related osteoporosis with current pathological fracture, right pelvis, subsequent encounter for fracture with malunion
M80.0B1S Age-related osteoporosis with current pathological fracture, right pelvis, sequela
M80.0B2A Age-related osteoporosis with current pathological fracture, left pelvis, initial encounter for fracture
M80.0B2D Age-related osteoporosis with current pathological fracture, left pelvis, subsequent encounter for fracture with routine healing
M80.0B2G Age-related osteoporosis with current pathological fracture, left pelvis, subsequent encounter for fracture with delayed healing
M80.0B2K Age-related osteoporosis with current pathological fracture, left pelvis, subsequent encounter for fracture with nonunion
M80.0B2P Age-related osteoporosis with current pathological fracture, left pelvis, subsequent encounter for fracture with malunion
M80.0B2S Age-related osteoporosis with current pathological fracture, left pelvis, sequela
M80.0B9A Age-related osteoporosis with current pathological fracture, unspecified pelvis, initial encounter for fracture
M80.0B9D Age-related osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with routine healing
M80.0B9G Age-related osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with delayed healing
M80.0B9K Age-related osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with nonunion
M80.0B9P Age-related osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with malunion
M80.0B9S Age-related osteoporosis with current pathological fracture, unspecified pelvis, sequela
M80.811A Other osteoporosis with current pathological fracture, right shoulder, initial encounter for fracture
M80.812A Other osteoporosis with current pathological fracture, left shoulder, initial encounter for fracture
M80.821A Other osteoporosis with current pathological fracture, right humerus, initial encounter for fracture
M80.822A Other osteoporosis with current pathological fracture, left humerus, initial encounter for fracture
M80.831A Other osteoporosis with current pathological fracture, right forearm, initial encounter for fracture
M80.832A Other osteoporosis with current pathological fracture, left forearm, initial encounter for fracture
M80.841A Other osteoporosis with current pathological fracture, right hand, initial encounter for fracture
M80.842A Other osteoporosis with current pathological fracture, left hand, initial encounter for fracture
M80.851A Other osteoporosis with current pathological fracture, right femur, initial encounter for fracture
M80.852A Other osteoporosis with current pathological fracture, left femur, initial encounter for fracture
M80.861A Other osteoporosis with current pathological fracture, right lower leg, initial encounter for fracture
M80.862A Other osteoporosis with current pathological fracture, left lower leg, initial encounter for fracture
M80.871A Other osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture
M80.872A Other osteoporosis with current pathological fracture, left ankle and foot, initial encounter for fracture
M80.88XA Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M80.8B1A Other osteoporosis with current pathological fracture, right pelvis, initial encounter for fracture
M80.8B1D Other osteoporosis with current pathological fracture, right pelvis, subsequent encounter for fracture with routine healing
M80.8B1G Other osteoporosis with current pathological fracture, right pelvis, subsequent encounter for fracture with delayed healing
M80.8B1K Other osteoporosis with current pathological fracture, right pelvis, subsequent encounter for fracture with nonunion
M80.8B1P Other osteoporosis with current pathological fracture, right pelvis, subsequent encounter for fracture with malunion
M80.8B1S Other osteoporosis with current pathological fracture, right pelvis, sequela
M80.8B2A Other osteoporosis with current pathological fracture, left pelvis, initial encounter for fracture
M80.8B2D Other osteoporosis with current pathological fracture, left pelvis, subsequent encounter for fracture with routine healing
M80.8B2G Other osteoporosis with current pathological fracture, left pelvis, subsequent encounter for fracture with delayed healing
M80.8B2K Other osteoporosis with current pathological fracture, left pelvis, subsequent encounter for fracture with nonunion
M80.8B2P Other osteoporosis with current pathological fracture, left pelvis, subsequent encounter for fracture with malunion
M80.8B2S Other osteoporosis with current pathological fracture, left pelvis, sequela
M80.8B9A Other osteoporosis with current pathological fracture, unspecified pelvis, initial encounter for fracture
M80.8B9D Other osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with routine healing
M80.8B9G Other osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with delayed healing
M80.8B9K Other osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with nonunion
M80.8B9P Other osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with malunion
M80.8B9S Other osteoporosis with current pathological fracture, unspecified pelvis, sequela
M81.0 Age-related osteoporosis without current pathological fracture
M81.6 Localized osteoporosis [Lequesne]
M81.8 Other osteoporosis without current pathological fracture
M85.80 Other specified disorders of bone density and structure, unspecified site
M85.811 Other specified disorders of bone density and structure, right shoulder
M85.812 Other specified disorders of bone density and structure, left shoulder
M85.821 Other specified disorders of bone density and structure, right upper arm
M85.822 Other specified disorders of bone density and structure, left upper arm
M85.831 Other specified disorders of bone density and structure, right forearm
M85.832 Other specified disorders of bone density and structure, left forearm
M85.841 Other specified disorders of bone density and structure, right hand
M85.842 Other specified disorders of bone density and structure, left hand
M85.851 Other specified disorders of bone density and structure, right thigh
M85.852 Other specified disorders of bone density and structure, left thigh
M85.861 Other specified disorders of bone density and structure, right lower leg
M85.862 Other specified disorders of bone density and structure, left lower leg
M85.871 Other specified disorders of bone density and structure, right ankle and foot
M85.872 Other specified disorders of bone density and structure, left ankle and foot
M88.0 Osteitis deformans of skull
M88.1 Osteitis deformans of vertebrae
M88.811 Osteitis deformans of right shoulder
M88.812 Osteitis deformans of left shoulder
M88.821 Osteitis deformans of right upper arm
M88.822 Osteitis deformans of left upper arm
M88.831 Osteitis deformans of right forearm
M88.832 Osteitis deformans of left forearm
M88.841 Osteitis deformans of right hand
M88.842 Osteitis deformans of left hand
M88.851 Osteitis deformans of right thigh
M88.852 Osteitis deformans of left thigh
M88.861 Osteitis deformans of right lower leg
M88.862 Osteitis deformans of left lower leg
M88.871 Osteitis deformans of right ankle and foot
M88.872 Osteitis deformans of left ankle and foot
M88.88 Osteitis deformans of other bones
M88.89 Osteitis deformans of multiple sites
M89.9 Disorder of bone, unspecified
M94.9 Disorder of cartilage, unspecified
T38.0X5A Adverse effect of glucocorticoids and synthetic analogues, initial encounter
T38.0X5D Adverse effect of glucocorticoids and synthetic analogues, subsequent encounter
T38.0X5S Adverse effect of glucocorticoids and synthetic analogues, sequela
T79.6XXA Traumatic ischemia of muscle, initial encounter
T79.6XXD Traumatic ischemia of muscle, subsequent encounter
T79.6XXS Traumatic ischemia of muscle, sequela
Z79.52 Long term (current) use of systemic steroids
Z79.810 Long term (current) use of selective estrogen receptor modulators (SERMs)
Z79.811 Long term (current) use of aromatase inhibitors
Z79.899 Other long term (current) drug therapy
Z85.3 Personal history of malignant neoplasm of breast
Z85.46 Personal history of malignant neoplasm of prostate
Z92.22 Personal history of monoclonal drug therapy

Group 2

(155 Codes)
Group 2 Paragraph

J2430 Pamidronate disodium

For C79.51 and C79.52, see Documentation Requirements L34648 Biphosphonate Drug Therapy.

For M85.80, M85.811, M85.812, M85.821, M85.822, M85.831, M85.832, M85.841, M85.842, M85.851, M85.852, M85.861, M85.862, M85.871, M85.872, M89.9 or M94.9, additional codes C50-011-C50.922 OR Z85.3, and Z79.810 OR Z79.811 must also be reported when the drug is used for treatment of bone loss in women or men receiving adjuvant selective estrogen receptor modulators OR aromatase inhibitor therapy for breast cancer.

For M85.80, M85.811, M85.812, M85.821, M85.822, M85.831, M85.832, M85.841, M85.842, M85.851, M85.852, M85.861, M85.862, M85.871, M85.872, M89.9 or M94.9, additional codes C61 OR Z85.46 and Z79.899 must also be reported when the drug is used for treatment of bone loss in men receiving androgen deprivation therapy for prostate cancer.

When billing for osteopenia, ICD-10 codes M85.80, M85.811, M85.812, M85.821, M85.822, M85.831, M85.832, M85.841, M85.842, M85.851, M85.852, M85.861, M85.862, M85.871, M85.872, M89.9, or M94.9 should be used.

Group 2 Codes
Code Description
C50.011 Malignant neoplasm of nipple and areola, right female breast
C50.012 Malignant neoplasm of nipple and areola, left female breast
C50.021 Malignant neoplasm of nipple and areola, right male breast
C50.022 Malignant neoplasm of nipple and areola, left male breast
C50.111 Malignant neoplasm of central portion of right female breast
C50.112 Malignant neoplasm of central portion of left female breast
C50.121 Malignant neoplasm of central portion of right male breast
C50.122 Malignant neoplasm of central portion of left male breast
C50.211 Malignant neoplasm of upper-inner quadrant of right female breast
C50.212 Malignant neoplasm of upper-inner quadrant of left female breast
C50.221 Malignant neoplasm of upper-inner quadrant of right male breast
C50.222 Malignant neoplasm of upper-inner quadrant of left male breast
C50.311 Malignant neoplasm of lower-inner quadrant of right female breast
C50.312 Malignant neoplasm of lower-inner quadrant of left female breast
C50.321 Malignant neoplasm of lower-inner quadrant of right male breast
C50.322 Malignant neoplasm of lower-inner quadrant of left male breast
C50.411 Malignant neoplasm of upper-outer quadrant of right female breast
C50.412 Malignant neoplasm of upper-outer quadrant of left female breast
C50.421 Malignant neoplasm of upper-outer quadrant of right male breast
C50.422 Malignant neoplasm of upper-outer quadrant of left male breast
C50.511 Malignant neoplasm of lower-outer quadrant of right female breast
C50.512 Malignant neoplasm of lower-outer quadrant of left female breast
C50.521 Malignant neoplasm of lower-outer quadrant of right male breast
C50.522 Malignant neoplasm of lower-outer quadrant of left male breast
C50.611 Malignant neoplasm of axillary tail of right female breast
C50.612 Malignant neoplasm of axillary tail of left female breast
C50.621 Malignant neoplasm of axillary tail of right male breast
C50.622 Malignant neoplasm of axillary tail of left male breast
C50.811 Malignant neoplasm of overlapping sites of right female breast
C50.812 Malignant neoplasm of overlapping sites of left female breast
C50.821 Malignant neoplasm of overlapping sites of right male breast
C50.822 Malignant neoplasm of overlapping sites of left male breast
C50.911 Malignant neoplasm of unspecified site of right female breast
C50.912 Malignant neoplasm of unspecified site of left female breast
C50.921 Malignant neoplasm of unspecified site of right male breast
C50.922 Malignant neoplasm of unspecified site of left male breast
C61 Malignant neoplasm of prostate
C79.51 Secondary malignant neoplasm of bone
C79.52 Secondary malignant neoplasm of bone marrow
C90.00 Multiple myeloma not having achieved remission
C90.01 Multiple myeloma in remission
C90.02 Multiple myeloma in relapse
D05.11 Intraductal carcinoma in situ of right breast
D05.12 Intraductal carcinoma in situ of left breast
D05.81 Other specified type of carcinoma in situ of right breast
D05.82 Other specified type of carcinoma in situ of left breast
D05.91 Unspecified type of carcinoma in situ of right breast
D05.92 Unspecified type of carcinoma in situ of left breast
E83.52 Hypercalcemia
M61.011 Myositis ossificans traumatica, right shoulder
M61.012 Myositis ossificans traumatica, left shoulder
M61.021 Myositis ossificans traumatica, right upper arm
M61.022 Myositis ossificans traumatica, left upper arm
M61.031 Myositis ossificans traumatica, right forearm
M61.032 Myositis ossificans traumatica, left forearm
M61.041 Myositis ossificans traumatica, right hand
M61.042 Myositis ossificans traumatica, left hand
M61.051 Myositis ossificans traumatica, right thigh
M61.052 Myositis ossificans traumatica, left thigh
M61.061 Myositis ossificans traumatica, right lower leg
M61.062 Myositis ossificans traumatica, left lower leg
M61.071 Myositis ossificans traumatica, right ankle and foot
M61.072 Myositis ossificans traumatica, left ankle and foot
M61.08 Myositis ossificans traumatica, other site
M61.09 Myositis ossificans traumatica, multiple sites
M61.111 Myositis ossificans progressiva, right shoulder
M61.112 Myositis ossificans progressiva, left shoulder
M61.121 Myositis ossificans progressiva, right upper arm
M61.122 Myositis ossificans progressiva, left upper arm
M61.131 Myositis ossificans progressiva, right forearm
M61.132 Myositis ossificans progressiva, left forearm
M61.141 Myositis ossificans progressiva, right hand
M61.142 Myositis ossificans progressiva, left hand
M61.144 Myositis ossificans progressiva, right finger(s)
M61.145 Myositis ossificans progressiva, left finger(s)
M61.151 Myositis ossificans progressiva, right thigh
M61.152 Myositis ossificans progressiva, left thigh
M61.161 Myositis ossificans progressiva, right lower leg
M61.162 Myositis ossificans progressiva, left lower leg
M61.171 Myositis ossificans progressiva, right ankle
M61.172 Myositis ossificans progressiva, left ankle
M61.174 Myositis ossificans progressiva, right foot
M61.175 Myositis ossificans progressiva, left foot
M61.177 Myositis ossificans progressiva, right toe(s)
M61.178 Myositis ossificans progressiva, left toe(s)
M61.18 Myositis ossificans progressiva, other site
M61.19 Myositis ossificans progressiva, multiple sites
M61.211 Paralytic calcification and ossification of muscle, right shoulder
M61.212 Paralytic calcification and ossification of muscle, left shoulder
M61.221 Paralytic calcification and ossification of muscle, right upper arm
M61.222 Paralytic calcification and ossification of muscle, left upper arm
M61.231 Paralytic calcification and ossification of muscle, right forearm
M61.232 Paralytic calcification and ossification of muscle, left forearm
M61.241 Paralytic calcification and ossification of muscle, right hand
M61.242 Paralytic calcification and ossification of muscle, left hand
M61.251 Paralytic calcification and ossification of muscle, right thigh
M61.252 Paralytic calcification and ossification of muscle, left thigh
M61.261 Paralytic calcification and ossification of muscle, right lower leg
M61.262 Paralytic calcification and ossification of muscle, left lower leg
M61.271 Paralytic calcification and ossification of muscle, right ankle and foot
M61.272 Paralytic calcification and ossification of muscle, left ankle and foot
M61.28 Paralytic calcification and ossification of muscle, other site
M61.29 Paralytic calcification and ossification of muscle, multiple sites
M81.0 Age-related osteoporosis without current pathological fracture
M81.6 Localized osteoporosis [Lequesne]
M81.8 Other osteoporosis without current pathological fracture
M85.80 Other specified disorders of bone density and structure, unspecified site
M85.811 Other specified disorders of bone density and structure, right shoulder
M85.812 Other specified disorders of bone density and structure, left shoulder
M85.821 Other specified disorders of bone density and structure, right upper arm
M85.822 Other specified disorders of bone density and structure, left upper arm
M85.831 Other specified disorders of bone density and structure, right forearm
M85.832 Other specified disorders of bone density and structure, left forearm
M85.841 Other specified disorders of bone density and structure, right hand
M85.842 Other specified disorders of bone density and structure, left hand
M85.851 Other specified disorders of bone density and structure, right thigh
M85.852 Other specified disorders of bone density and structure, left thigh
M85.861 Other specified disorders of bone density and structure, right lower leg
M85.862 Other specified disorders of bone density and structure, left lower leg
M85.871 Other specified disorders of bone density and structure, right ankle and foot
M85.872 Other specified disorders of bone density and structure, left ankle and foot
M88.0 Osteitis deformans of skull
M88.1 Osteitis deformans of vertebrae
M88.811 Osteitis deformans of right shoulder
M88.812 Osteitis deformans of left shoulder
M88.821 Osteitis deformans of right upper arm
M88.822 Osteitis deformans of left upper arm
M88.831 Osteitis deformans of right forearm
M88.832 Osteitis deformans of left forearm
M88.841 Osteitis deformans of right hand
M88.842 Osteitis deformans of left hand
M88.851 Osteitis deformans of right thigh
M88.852 Osteitis deformans of left thigh
M88.861 Osteitis deformans of right lower leg
M88.862 Osteitis deformans of left lower leg
M88.871 Osteitis deformans of right ankle and foot
M88.872 Osteitis deformans of left ankle and foot
M88.88 Osteitis deformans of other bones
M88.89 Osteitis deformans of multiple sites
M89.9 Disorder of bone, unspecified
M94.9 Disorder of cartilage, unspecified
Q77.3 Chondrodysplasia punctata
Q78.0 Osteogenesis imperfecta
Q78.1 Polyostotic fibrous dysplasia
Q78.5 Metaphyseal dysplasia
Q78.6 Multiple congenital exostoses
Q78.8 Other specified osteochondrodysplasias
T79.6XXA Traumatic ischemia of muscle, initial encounter
T79.6XXD Traumatic ischemia of muscle, subsequent encounter
T79.6XXS Traumatic ischemia of muscle, sequela
Z79.810 Long term (current) use of selective estrogen receptor modulators (SERMs)
Z79.811 Long term (current) use of aromatase inhibitors
Z79.899 Other long term (current) drug therapy
Z85.3 Personal history of malignant neoplasm of breast
Z85.46 Personal history of malignant neoplasm of prostate

Group 3

(94 Codes)
Group 3 Paragraph

J1740 Ibandronate sodium

For codes in the table below that require a 7th character, letter A initial encounter for fracture, D subsequent encounter for fracture with routine healing, G subsequent encounter for fracture with delayed healing, K for subsequent encounter for fracture with nonunion, P for subsequent encounter for fracture with malunion, or S sequela may be used.

For C79.51 and C79.52, see Documentation Requirements L34648 Biphosphonate Drug Therapy.

When billing for osteopenia, ICD-10 codes M85.80, M85.811, M85.812, M85.821, M85.822, M85.831, M85.832, M85.841, M85.842, M85.851, M85.852, M85.861, M85.862, M85.871, M85.872, M89.9, or M94.9 should be used.

Group 3 Codes
Code Description
C79.51 Secondary malignant neoplasm of bone
C79.52 Secondary malignant neoplasm of bone marrow
E83.52 Hypercalcemia
M80.011A Age-related osteoporosis with current pathological fracture, right shoulder, initial encounter for fracture
M80.012A Age-related osteoporosis with current pathological fracture, left shoulder, initial encounter for fracture
M80.021A Age-related osteoporosis with current pathological fracture, right humerus, initial encounter for fracture
M80.022A Age-related osteoporosis with current pathological fracture, left humerus, initial encounter for fracture
M80.031A Age-related osteoporosis with current pathological fracture, right forearm, initial encounter for fracture
M80.032A Age-related osteoporosis with current pathological fracture, left forearm, initial encounter for fracture
M80.041A Age-related osteoporosis with current pathological fracture, right hand, initial encounter for fracture
M80.042A Age-related osteoporosis with current pathological fracture, left hand, initial encounter for fracture
M80.051A Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture
M80.052A Age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture
M80.061A Age-related osteoporosis with current pathological fracture, right lower leg, initial encounter for fracture
M80.062A Age-related osteoporosis with current pathological fracture, left lower leg, initial encounter for fracture
M80.071A Age-related osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture
M80.072A Age-related osteoporosis with current pathological fracture, left ankle and foot, initial encounter for fracture
M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M80.0B1A Age-related osteoporosis with current pathological fracture, right pelvis, initial encounter for fracture
M80.0B1D Age-related osteoporosis with current pathological fracture, right pelvis, subsequent encounter for fracture with routine healing
M80.0B1G Age-related osteoporosis with current pathological fracture, right pelvis, subsequent encounter for fracture with delayed healing
M80.0B1K Age-related osteoporosis with current pathological fracture, right pelvis, subsequent encounter for fracture with nonunion
M80.0B1P Age-related osteoporosis with current pathological fracture, right pelvis, subsequent encounter for fracture with malunion
M80.0B1S Age-related osteoporosis with current pathological fracture, right pelvis, sequela
M80.0B2A Age-related osteoporosis with current pathological fracture, left pelvis, initial encounter for fracture
M80.0B2D Age-related osteoporosis with current pathological fracture, left pelvis, subsequent encounter for fracture with routine healing
M80.0B2G Age-related osteoporosis with current pathological fracture, left pelvis, subsequent encounter for fracture with delayed healing
M80.0B2K Age-related osteoporosis with current pathological fracture, left pelvis, subsequent encounter for fracture with nonunion
M80.0B2P Age-related osteoporosis with current pathological fracture, left pelvis, subsequent encounter for fracture with malunion
M80.0B2S Age-related osteoporosis with current pathological fracture, left pelvis, sequela
M80.0B9A Age-related osteoporosis with current pathological fracture, unspecified pelvis, initial encounter for fracture
M80.0B9D Age-related osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with routine healing
M80.0B9G Age-related osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with delayed healing
M80.0B9K Age-related osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with nonunion
M80.0B9P Age-related osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with malunion
M80.0B9S Age-related osteoporosis with current pathological fracture, unspecified pelvis, sequela
M80.811A Other osteoporosis with current pathological fracture, right shoulder, initial encounter for fracture
M80.812A Other osteoporosis with current pathological fracture, left shoulder, initial encounter for fracture
M80.821A Other osteoporosis with current pathological fracture, right humerus, initial encounter for fracture
M80.822A Other osteoporosis with current pathological fracture, left humerus, initial encounter for fracture
M80.831A Other osteoporosis with current pathological fracture, right forearm, initial encounter for fracture
M80.832A Other osteoporosis with current pathological fracture, left forearm, initial encounter for fracture
M80.841A Other osteoporosis with current pathological fracture, right hand, initial encounter for fracture
M80.842A Other osteoporosis with current pathological fracture, left hand, initial encounter for fracture
M80.851A Other osteoporosis with current pathological fracture, right femur, initial encounter for fracture
M80.852A Other osteoporosis with current pathological fracture, left femur, initial encounter for fracture
M80.861A Other osteoporosis with current pathological fracture, right lower leg, initial encounter for fracture
M80.862A Other osteoporosis with current pathological fracture, left lower leg, initial encounter for fracture
M80.871A Other osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture
M80.872A Other osteoporosis with current pathological fracture, left ankle and foot, initial encounter for fracture
M80.88XA Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture
M80.8B1A Other osteoporosis with current pathological fracture, right pelvis, initial encounter for fracture
M80.8B1D Other osteoporosis with current pathological fracture, right pelvis, subsequent encounter for fracture with routine healing
M80.8B1G Other osteoporosis with current pathological fracture, right pelvis, subsequent encounter for fracture with delayed healing
M80.8B1K Other osteoporosis with current pathological fracture, right pelvis, subsequent encounter for fracture with nonunion
M80.8B1P Other osteoporosis with current pathological fracture, right pelvis, subsequent encounter for fracture with malunion
M80.8B1S Other osteoporosis with current pathological fracture, right pelvis, sequela
M80.8B2A Other osteoporosis with current pathological fracture, left pelvis, initial encounter for fracture
M80.8B2D Other osteoporosis with current pathological fracture, left pelvis, subsequent encounter for fracture with routine healing
M80.8B2G Other osteoporosis with current pathological fracture, left pelvis, subsequent encounter for fracture with delayed healing
M80.8B2K Other osteoporosis with current pathological fracture, left pelvis, subsequent encounter for fracture with nonunion
M80.8B2P Other osteoporosis with current pathological fracture, left pelvis, subsequent encounter for fracture with malunion
M80.8B2S Other osteoporosis with current pathological fracture, left pelvis, sequela
M80.8B9A Other osteoporosis with current pathological fracture, unspecified pelvis, initial encounter for fracture
M80.8B9D Other osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with routine healing
M80.8B9G Other osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with delayed healing
M80.8B9K Other osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with nonunion
M80.8B9P Other osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with malunion
M80.8B9S Other osteoporosis with current pathological fracture, unspecified pelvis, sequela
M81.0 Age-related osteoporosis without current pathological fracture
M81.6 Localized osteoporosis [Lequesne]
M81.8 Other osteoporosis without current pathological fracture
M85.80 Other specified disorders of bone density and structure, unspecified site
M85.811 Other specified disorders of bone density and structure, right shoulder
M85.812 Other specified disorders of bone density and structure, left shoulder
M85.821 Other specified disorders of bone density and structure, right upper arm
M85.822 Other specified disorders of bone density and structure, left upper arm
M85.831 Other specified disorders of bone density and structure, right forearm
M85.832 Other specified disorders of bone density and structure, left forearm
M85.841 Other specified disorders of bone density and structure, right hand
M85.842 Other specified disorders of bone density and structure, left hand
M85.851 Other specified disorders of bone density and structure, right thigh
M85.852 Other specified disorders of bone density and structure, left thigh
M85.861 Other specified disorders of bone density and structure, right lower leg
M85.862 Other specified disorders of bone density and structure, left lower leg
M85.871 Other specified disorders of bone density and structure, right ankle and foot
M85.872 Other specified disorders of bone density and structure, left ankle and foot
M85.9 Disorder of bone density and structure, unspecified
M89.9 Disorder of bone, unspecified
M94.9 Disorder of cartilage, unspecified
T38.0X5A Adverse effect of glucocorticoids and synthetic analogues, initial encounter
T38.0X5D Adverse effect of glucocorticoids and synthetic analogues, subsequent encounter
T38.0X5S Adverse effect of glucocorticoids and synthetic analogues, sequela
Z79.52 Long term (current) use of systemic steroids
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
02/11/2024 R8

Posted 02/29/2024: The following statements were corrected from the previous revision history: Under ICD-10-CM Codes that Support Medical Necessity Group 1 Codes: added Z92.22. Under ICD-10-CM Codes that Support Medical Necessity Group 1 and Group 3 Codes: added T38.0X5A, T38.0X5D, and Z79.52. Under ICD-10-CM Codes that Support Medical Necessity Group 1 and Group 2 Paragraphs, added statement that C61 may be reported when the drug is used for treatment of bone loss in men receiving androgen deprivation therapy for prostate cancer.

02/11/2024 R7

Posted 12/28/2023: Under Article Guidance, added sections titled Documentation Requirements and Utilization Guidelines. Under ICD-10-CM Codes that Support Medical Necessity Group 1 and Group 2 Paragraphs, added that C61 may be reported when the drug is used for treatment of bone loss in men receiving androgen deprivation therapy for prostate cancer. Added the following paragraph under ICD-10-CM Codes that Support Medical Necessity Group 1, Group 2, and Group 3 Paragraphs: When billing for osteopenia, ICD-10 codes M85.80, M85.811, M85.812, M85.821, M85.822, M85.831, M85.832, M85.841, M85.842, M85.851, M85.852, M85.861, M85.862, M85.871, M85.872, M89.9, or M94.9 should be used. Added the following codes under ICD-10-CM Codes that Support Medical Necessity Group 1 and Group 2 Codes: C61, D05.11, D05.12, D05.81, D05.82, D05.91, D05.92, T38.0X5A, T38.0X5D, T38.0X5S, Z92.22. Added the following codes under ICD-10-CM Codes that Support Medical Necessity Group 3 Codes: M85.80, M85.811, M85.812, M85.821, M85.822, M85.831, M85.832, M85.841, M85.842, M85.851, M85.852, M85.861, M85.862, M85.871, M85.872, M85.9, M89.9, M94.9, T38.0X5A, T38.0X5D, T38.0X5S, Z79.52. Under ICD-10-CM Codes that DO NOT Support Medical Necessity, deleted Group 1 Paragraph and all codes listed under Group 1 Codes. No changes were made between the draft and final versions of the billing and coding article.

10/01/2023 R6

Posted 09/28/2023: Under ICD-10-CM Codes that Support Medical Necessity, added the following codes to Group 1 & Group 3: M80.0B1A, M80.0B1D, M80.0B1G, M80.0B1K, M80.0B1P, M80.0B1S, M80.0B2A, M80.0B2D, M80.0B2G, M80.0B2K, M80.0B2P, M80.0B2S, M80.0B9A, M80.0B9D, M80.0B9G, M80.0B9K, M80.0B9P, M80.0B9S, M80.8B1A, M80.8B1D, M80.8B1G, M80.8B1K, M80.8B1P, M80.8B1S, M80.8B2A, M80.8B2D, M80.8B2G, M80.8B2K, M80.8B2P, M80.8B2S, M80.8B9A, M80.8B9D, M80.8B9G, M80.8B9K, M80.8B9P, M80.8B9S. These updates are due to the 2024 Annual ICD-10-CM Code Updates and are effective 10/01/2023.

07/28/2022 R5

Posted 07/28/2022: Added Z79.810 to Group 1 and Group 2 codes. Added the following to Group 1 and Group 2 codes: C50.011, C50.012, C50.021, C50.022, C50.111, C50.112, C50.121, C50.122, C50.211, C50.212, C50.221, C50.222, C50.311, C50.312, C50.321, C50.322, C50.411, C50.412, C50.421, C50.422, C50.511, C50.512, C50.521, C50.522, C50.611, C50.612, C50.621, C50.622, C50.811, C50.812, C50.821, C50.822, C50.911, C50.912, C50.921, C50.922. Added language in the Group 1 and Group 2 paragraphs to clarify that Z79.810 must be reported when the drug is used for treatment of bone loss in women or men receiving adjuvant selective estrogen receptor modulators therapy for breast cancer, along with the appropriate breast cancer diagnosis code. Removed “non metastatic” from before the words “prostate cancer” in the Group 1 and Group 2 paragraphs, as this was a typographical error. Corrected other minor typographical errors throughout the article. Review completed 07/05/2022.

08/27/2020 R4

08/27/2020 Removed J1436 from the CPT/HCPCS codes section as it is no longer available in the United States. Also removed the related paragraph and table under the ICD-10 Codes That Support Medical Necessity section. Renumbered the ICD-10 code paragraphs and tables. Review completed 07/15/2020.

03/26/2020 R3

03/26/2020 Added M85.80 to ICD-10 Codes That Support Medical Necessity Group Paragraphs 1, 2 and 3 and Tables 1, 2 and 3. The code was also added to the ICD-10 Codes That Are Not Covered Group 1 Paragraph and Table with reference to exceptions.

10/31/2019 R2

10/31/2019 Removed language and ICD-10 codes for cancer treatment related osteopenia that were unintentionally added to ICD-10 Codes That Support Medical Necessity: Group 4.

08/29/2019 R1

09/26/2019 Added the following codes to ICD-10 Codes That Support Medical Necessity Group Paragraphs 1, 2, 3 and 4 and Tables 1, 2, 3 and 4, along with the related coding guidance for when the drug is used for cancer treatment related osteopenia: M85.811, M85.812, M85.821, M85.822, M85.831, M85.832, M85.841, M85.842, M85.851, M85.852, M85.861, M85.862, M85.871 and M85.872. The same codes were also added to the Not Covered Group 1 Paragraph and Table with reference to exceptions. Removed redundant language.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
02/21/2024 02/11/2024 - N/A Currently in Effect You are here
12/20/2023 02/11/2024 - N/A Superseded View
09/19/2023 10/01/2023 - 02/10/2024 Superseded View
07/20/2022 07/28/2022 - 09/30/2023 Superseded View
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Keywords

  • Osteoporosis
  • osteopenia