Coverage Indications, Limitations, and/or Medical Necessity
Bone and/or joint imaging, also known as a Bone scan, skeletal scintigraphy, or a radionuclide bone scan is a nuclear medicine study utilizing an intravenous injection of a technetium-99m phosphonate radiopharmaceutical which localizes in bone with intensity proportional to the degree of metabolic activity present. This diagnostic study records the distribution of this radioactive tracer in the skeletal system in planar (two-dimensional) and/or tomographic (three-dimensional) images normally 2-4 hours after the injection of the radiopharmaceutical agent.
A whole body bone scan produces planar images of the skeleton including anterior and posterior views of the axial skeleton. Anterior and/or posterior views of the appendicular skeleton are also obtained. Additional views may be obtained as needed. The limited bone scan records images of only a portion of the skeleton.
Bone single photon emission computed tomography (SPECT) produces a tomographic image of a portion of the skeleton. This technique increases diagnostic accuracy by improving sensitivity, providing more precise localization of the radiopharmaceutical, and allowing improved visualization of subtle abnormalities.
Three-phase imaging, also known as multiphase bone scintigraphy consists of blood flow images, immediate images and delayed images and is utilized to distinguish skeletal from soft-tissue infection. The blood flow images consist of a dynamic sequence of planar images of the area of greatest interest obtained as the tracer is injected. The immediate (blood pool) images consist of one or more static planar images of the areas of interest, obtained within 10 minutes after injection of the tracer. Delayed images may be limited to the areas of interest or may include the whole body, may be planar or tomographic, and are usually acquired 2 to 5 hours after injection. Further additional images obtained up to 24 hours following the tracer injection may be obtained if necessary.
Bone and/or joint imaging will be considered medically reasonable and necessary for the following indications:
· Extraskeletal primary malignancies for the presence of metastatic disease. The application of imaging in these patients include initial staging, protocol monitoring in response to chemotherapy and decision to change therapy, radiation therapy for treatment field planning and response to radiation therapy, and detection of areas at risk for pathological fracture.
· Primary malignant bone tumors when metastasis is suspected. Normally, plain radiographs, CT and MRI are a better diagnostic test to portray the tumor margins in bone and allow assessment of soft tissue extent. However, a whole body scan is appropriate to assess osseous metastasis.
· Benign bone tumors including osteoid osteomas, osteochondromas, chondroblastomas and enchondromas.
· Skeletal trauma to evaluate the presence of occult fractures when the initial standard radiographic procedure is normal and the clinical presentation is highly suspicious of fracture.
· Assessing the full extent of injury in patients with multiple injuries.
· Athletic injuries to evaluate for stress fractures and shin splints.
· Determine bone viability in infarction, osteonecrosis, and grafts.
· Osteomyelitis. The evaluation of osteomyelitis is performed utilizing the triple-phase bone scan. This technique is used to differentiate osteomyelitis from cellulitis.
· Diagnosis and evaluation of musculoskeletal infections to rule out bone involvement. A triple-phase bone scan is utilized for this indication.
· Metabolic bone disease such as osteoporosis and Paget’s Disease when the results of the bone scan will be used to guide treatment.
· Diagnosis and evaluation of reflex sympathetic dystrophy. The evaluation of reflex sympathetic dystrophy is performed utilizing the triple-phase bone scan.
· Evaluate a prosthetic joint for loosening or infection.
· Unexplained musculoskeletal pain when the initial standard radiographic procedure fails to determine the etiology and a musculoskeletal etiology is suspected.
· Evaluation of abnormal radiographic findings or abnormal laboratory findings demonstrating skeletal involvement.
· Determine the distribution of osteoblastic activity prior to therapy with strontium-89.
Note: as indicated above, the triple-phase bone scan is normally utilized to evaluate, but not limited to: osteomyelitis; diagnose and evaluate musculoskeletal infections to rule out bone involvement; and to diagnose and evaluate reflex sympathetic dystrophy. Therefore, it is expected that this technique is utilized to evaluate these conditions.
Skeletal scintigraphy is a sensitive marker of both osteoarthritis and rheumatoid arthritis. Numerous attempts have been made over the last two decades to develop scintigraphic techniques for staging the severity of arthritis and assessing response to therapy. These have been largely unsuccessful, and skeletal scintigraphy, although not common, may be used to evaluate arthritis in current clinical practice.
It is expected that a whole body scan (procedure code 78306) is performed only when an evaluation of the entire skeletal system is necessary, such as the evaluation for metastatic disease, or for the evaluation of localized pain of unknown etiology. A limited or multiple area body scan is medically necessary when the patient’s signs, symptoms, or condition is limited to a certain body area. For example, it is expected that a limited bone scan be performed on patients with a stress fracture of the foot. A multiple area body scan is necessary in conditions in which more than one body area is affected; however, a total assessment of the skeletal system is not needed. A triple-phase body scan is medically necessary for the assessment of the skeletal system to differentiate a skeletal infection versus a soft tissue infection.
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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
CODE DESCRIPTION
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
014x Hospital - Laboratory Services Provided to Non-patients
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
085x Critical Access Hospital
CPT/HCPCS Codes
Group 1 Paragraph: N/A
Group 1 Codes:
CODE DESCRIPTION
78300 BONE AND/OR JOINT IMAGING; LIMITED AREA
78305 BONE AND/OR JOINT IMAGING; MULTIPLE AREAS
78306 BONE AND/OR JOINT IMAGING; WHOLE BODY
78315 BONE AND/OR JOINT IMAGING; 3 PHASE STUDY
78320 BONE AND/OR JOINT IMAGING; TOMOGRAPHIC (SPECT)
References:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33272&ver=9&DocType=2&bc=AAIAAAAAAAAA&
Bone and/or joint imaging, also known as a Bone scan, skeletal scintigraphy, or a radionuclide bone scan is a nuclear medicine study utilizing an intravenous injection of a technetium-99m phosphonate radiopharmaceutical which localizes in bone with intensity proportional to the degree of metabolic activity present. This diagnostic study records the distribution of this radioactive tracer in the skeletal system in planar (two-dimensional) and/or tomographic (three-dimensional) images normally 2-4 hours after the injection of the radiopharmaceutical agent.
A whole body bone scan produces planar images of the skeleton including anterior and posterior views of the axial skeleton. Anterior and/or posterior views of the appendicular skeleton are also obtained. Additional views may be obtained as needed. The limited bone scan records images of only a portion of the skeleton.
Bone single photon emission computed tomography (SPECT) produces a tomographic image of a portion of the skeleton. This technique increases diagnostic accuracy by improving sensitivity, providing more precise localization of the radiopharmaceutical, and allowing improved visualization of subtle abnormalities.
Three-phase imaging, also known as multiphase bone scintigraphy consists of blood flow images, immediate images and delayed images and is utilized to distinguish skeletal from soft-tissue infection. The blood flow images consist of a dynamic sequence of planar images of the area of greatest interest obtained as the tracer is injected. The immediate (blood pool) images consist of one or more static planar images of the areas of interest, obtained within 10 minutes after injection of the tracer. Delayed images may be limited to the areas of interest or may include the whole body, may be planar or tomographic, and are usually acquired 2 to 5 hours after injection. Further additional images obtained up to 24 hours following the tracer injection may be obtained if necessary.
Bone and/or joint imaging will be considered medically reasonable and necessary for the following indications:
· Extraskeletal primary malignancies for the presence of metastatic disease. The application of imaging in these patients include initial staging, protocol monitoring in response to chemotherapy and decision to change therapy, radiation therapy for treatment field planning and response to radiation therapy, and detection of areas at risk for pathological fracture.
· Primary malignant bone tumors when metastasis is suspected. Normally, plain radiographs, CT and MRI are a better diagnostic test to portray the tumor margins in bone and allow assessment of soft tissue extent. However, a whole body scan is appropriate to assess osseous metastasis.
· Benign bone tumors including osteoid osteomas, osteochondromas, chondroblastomas and enchondromas.
· Skeletal trauma to evaluate the presence of occult fractures when the initial standard radiographic procedure is normal and the clinical presentation is highly suspicious of fracture.
· Assessing the full extent of injury in patients with multiple injuries.
· Athletic injuries to evaluate for stress fractures and shin splints.
· Determine bone viability in infarction, osteonecrosis, and grafts.
· Osteomyelitis. The evaluation of osteomyelitis is performed utilizing the triple-phase bone scan. This technique is used to differentiate osteomyelitis from cellulitis.
· Diagnosis and evaluation of musculoskeletal infections to rule out bone involvement. A triple-phase bone scan is utilized for this indication.
· Metabolic bone disease such as osteoporosis and Paget’s Disease when the results of the bone scan will be used to guide treatment.
· Diagnosis and evaluation of reflex sympathetic dystrophy. The evaluation of reflex sympathetic dystrophy is performed utilizing the triple-phase bone scan.
· Evaluate a prosthetic joint for loosening or infection.
· Unexplained musculoskeletal pain when the initial standard radiographic procedure fails to determine the etiology and a musculoskeletal etiology is suspected.
· Evaluation of abnormal radiographic findings or abnormal laboratory findings demonstrating skeletal involvement.
· Determine the distribution of osteoblastic activity prior to therapy with strontium-89.
Note: as indicated above, the triple-phase bone scan is normally utilized to evaluate, but not limited to: osteomyelitis; diagnose and evaluate musculoskeletal infections to rule out bone involvement; and to diagnose and evaluate reflex sympathetic dystrophy. Therefore, it is expected that this technique is utilized to evaluate these conditions.
Skeletal scintigraphy is a sensitive marker of both osteoarthritis and rheumatoid arthritis. Numerous attempts have been made over the last two decades to develop scintigraphic techniques for staging the severity of arthritis and assessing response to therapy. These have been largely unsuccessful, and skeletal scintigraphy, although not common, may be used to evaluate arthritis in current clinical practice.
It is expected that a whole body scan (procedure code 78306) is performed only when an evaluation of the entire skeletal system is necessary, such as the evaluation for metastatic disease, or for the evaluation of localized pain of unknown etiology. A limited or multiple area body scan is medically necessary when the patient’s signs, symptoms, or condition is limited to a certain body area. For example, it is expected that a limited bone scan be performed on patients with a stress fracture of the foot. A multiple area body scan is necessary in conditions in which more than one body area is affected; however, a total assessment of the skeletal system is not needed. A triple-phase body scan is medically necessary for the assessment of the skeletal system to differentiate a skeletal infection versus a soft tissue infection.
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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
CODE DESCRIPTION
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
014x Hospital - Laboratory Services Provided to Non-patients
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
085x Critical Access Hospital
CPT/HCPCS Codes
Group 1 Paragraph: N/A
Group 1 Codes:
CODE DESCRIPTION
78300 BONE AND/OR JOINT IMAGING; LIMITED AREA
78305 BONE AND/OR JOINT IMAGING; MULTIPLE AREAS
78306 BONE AND/OR JOINT IMAGING; WHOLE BODY
78315 BONE AND/OR JOINT IMAGING; 3 PHASE STUDY
78320 BONE AND/OR JOINT IMAGING; TOMOGRAPHIC (SPECT)
References:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33272&ver=9&DocType=2&bc=AAIAAAAAAAAA&
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