Billing and Coding: Bisphosphonate Drug Therapy

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.