Does Medicare Pay for Trabecular Bone Score (TBS)? Here's What You Need to Know

Since 2022, the U.S. Centers for Medicare and Medicaid Services (CMS) has offered reimbursement for software that performs trabecular bone scores (TBS). This means that, in many cases, Medicare will pay for a trabecular bone score when performed alongside a standard bone density (DXA) scan, provided the beneficiary meets specific medical criteria. However, coverage is not automatic and depends on several factors.

Quick Summary

Medicare offers coverage for the trabecular bone score (TBS) procedure when performed with a standard bone density (DXA) scan for eligible beneficiaries. Coverage is tied to specific medical necessity criteria and uses dedicated CPT codes for reimbursement. Out-of-pocket costs and requirements can differ depending on the type of Medicare plan, provider participation, and facility type.

Key Points

• Medicare Covers TBS: Medicare Part B reimburses for the Trabecular Bone Score (TBS) when performed alongside a standard DXA scan.

• Requires Medical Necessity: Coverage is dependent on meeting specific medical criteria related to osteoporosis risk, steroid use, or monitoring drug therapy.

• Depends on Plan Type: With Original Medicare, a covered TBS is typically free if the provider accepts assignment, while Medicare Advantage plan costs can vary.

• Uses Dedicated CPT Codes: Correct billing is critical for reimbursement, and TBS utilizes its own Category I CPT® codes, not just a modifier on the DXA code.

• Enhances Fracture Risk Assessment: TBS analyzes bone microarchitecture to provide a more comprehensive evaluation of bone quality and fracture risk beyond a standard DXA scan.

• Must Accompany DXA Scan: The TBS is a software analysis of a DXA scan and cannot be billed or performed as a standalone service.

Medicare Coverage for Trabecular Bone Score: The Basics

Medicare Part B covers bone mass measurements, including Dual-energy X-ray Absorptiometry (DXA) scans, typically once every 24 months for qualifying individuals. The trabecular bone score (TBS) is an analysis performed on the data from a DXA scan that assesses bone microarchitecture, providing additional information about fracture risk. Since CMS established dedicated CPT codes in 2022, Medicare will reimburse providers for the TBS analysis when conducted in conjunction with a DXA scan for eligible patients.

For coverage to be provided, the procedure must be deemed medically necessary by a healthcare provider. This means the patient must meet specific medical conditions similar to those for standard bone mass measurements. The full list of eligibility criteria can be found in the {Link: USA Trabecular Bone Score Reimbursement and Coding Guide https://www.medimaps.ai/wp-content/uploads/2024/12/Reimbursement-and-coding-guide.pdf}.

Correct coding is crucial for providers to receive payment for TBS. TBS analysis utilizes its own set of dedicated Category I CPT codes, rather than simply being an add-on to the DXA code. Details on the specific CPT codes can be found in the {Link: USA Trabecular Bone Score Reimbursement and Coding Guide https://www.medimaps.ai/wp-content/uploads/2024/12/Reimbursement-and-coding-guide.pdf}. Coverage for TBS can vary depending on whether you have Original Medicare (Parts A and B) or a Medicare Advantage (Part C) plan. Here is a comparison:

Feature	Original Medicare (Part A & B)	Medicare Advantage (Part C)
Coverage	Part B covers TBS as part of bone mass measurements, generally every 24 months, if medically necessary.	Must cover at least the same benefits as Original Medicare, including TBS.
Out-of-Pocket Costs	If eligible and the provider accepts Medicare assignment, you typically pay nothing.	Costs vary by plan and may include deductibles, copayments, or coinsurance. Out-of-network costs can be higher.
Provider Network	Generally accepted by most providers nationwide who accept Medicare.	May require using in-network providers for full coverage.
Referral Requirements	No referral is usually needed if the ordering provider is in the Medicare network.	Some plans, like HMOs, might require a referral from your primary care provider.

How to Help Ensure Your TBS Procedure is Covered

1. Confirm Medical Necessity: Discuss with your doctor if you meet Medicare's criteria for a bone mass measurement, which is required for TBS coverage.
2. Check Your Plan Details: If you have a Medicare Advantage plan, contact your provider directly to understand coverage rules, network requirements, and potential costs.
3. Choose a Participating Provider: Verify that the facility performing the DXA/TBS scan accepts Medicare. If they accept "Medicare assignment" with Original Medicare, you should have no out-of-pocket expenses.
4. Ensure Proper Documentation: Your doctor's order and medical records should clearly support the medical necessity for the test according to Medicare's guidelines.

The Role of TBS in Assessing Osteoporosis Risk

The trabecular bone score enhances osteoporosis assessment by evaluating bone microarchitecture and quality, in addition to the bone mineral density measured by a standard DXA scan. This provides a more complete understanding of fracture risk, especially for individuals with seemingly normal bone density but poor bone quality.

By integrating both DXA and TBS results, healthcare providers can make more informed decisions regarding fracture prevention and treatment. The recognition of this clinical value led CMS to establish specific reimbursement pathways for TBS. This helps doctors get a more complete assessment of your fracture risk, which can lead to more tailored prevention or treatment plans, particularly if DXA results are borderline or don't fully explain your risk.

Conclusion

Does Medicare pay for trabecular bone score? Yes, Medicare does provide coverage for the trabecular bone score (TBS) when performed alongside a standard bone mass measurement (DXA scan) for eligible beneficiaries. Key steps for coverage include meeting medical necessity criteria, understanding your specific Medicare plan (especially Medicare Advantage), and ensuring the provider uses the correct CPT codes. By understanding these factors, you can effectively manage your bone health.

Frequently Asked Questions About TBS and Medicare

How often will Medicare pay for a bone density test and TBS? Medicare Part B typically covers a bone mass measurement, which includes the TBS analysis, once every 24 months. More frequent testing may be covered if medically necessary based on specific risk factors, such as monitoring osteoporosis treatment.

Do I have to pay anything for a covered TBS procedure? With Original Medicare, if you meet the eligibility criteria and the provider accepts Medicare assignment, you usually have no out-of-pocket costs for this covered preventive service. If you have a Medicare Advantage plan, costs can vary and may include copayments, deductibles, or coinsurance depending on your plan and network.

Can a TBS be done without a DXA scan? No, the trabecular bone score is an analysis of data obtained from a DXA scan. It cannot be performed as a separate procedure. For Medicare coverage, it must be performed with a standard DXA scan.

How do I know if my doctor can provide a TBS? Not all facilities are equipped with the software for TBS analysis. You should ask your doctor or the imaging center if they offer TBS in conjunction with a DXA scan.

Does Medicare Part D cover TBS? No, Medicare Part D covers prescription medications. The trabecular bone score procedure is a diagnostic service covered under Medicare Part B, which addresses outpatient medical services.

Is there an age requirement for Medicare to cover a TBS? Medicare Part B does not have a specific age requirement for bone mass measurements beyond qualifying for Medicare. However, coverage is based on specific risk factors for osteoporosis, which are often more prevalent with age.

How can a TBS score help my doctor? The TBS provides information on bone quality, complementing the bone density data from a DXA scan. This helps doctors get a more complete assessment of your fracture risk, which can lead to more tailored prevention or treatment plans, particularly if DXA results are borderline or don't fully explain your risk.

Frequently Asked Questions

Does Medicare pay for trabecular bone score as a standalone test?

No, the trabecular bone score (TBS) is a software analysis of the images from a standard bone density (DXA) scan. Therefore, it cannot be performed or reimbursed by Medicare as a standalone test; it must be done in conjunction with a DXA scan.

What is the CPT code for a trabecular bone score with Medicare?

The specific CPT code depends on how the service is billed. Code 77089 is used for the complete service when performed at the imaging equipment, while separate codes (77091 for the technical component and 77092 for the professional interpretation) are used for split billing.

How often will Medicare cover a TBS procedure?

Medicare Part B covers a bone mass measurement, which can include the TBS, once every 24 months. More frequent testing is covered if it is deemed medically necessary and the patient meets specific criteria, such as being monitored for osteoporosis drug therapy.

Will I have a copay for my TBS with a Medicare Advantage plan?

Copayments, deductibles, or coinsurance for a TBS with a Medicare Advantage plan can vary. You should contact your specific plan to confirm your potential out-of-pocket costs, as requirements and network rules differ from Original Medicare.

Do I need a referral to get a TBS covered by Medicare?

For Original Medicare, a referral is typically not required as long as the provider orders the test based on medical necessity and accepts Medicare. Some Medicare Advantage plans, particularly HMOs, may require a referral from your primary care provider.

Is the TBS considered a preventive service?

Yes, when performed according to the frequency guidelines, the bone mass measurement (including TBS) is a preventive service covered under Medicare Part B. For Original Medicare beneficiaries, there are typically no out-of-pocket costs for covered preventive services if the provider accepts assignment.

How can I verify my eligibility for Medicare coverage of a TBS?

You should talk to your doctor to determine if you meet one of the conditions listed for coverage, such as estrogen deficiency or steroid therapy. The doctor's documentation of medical necessity is key to receiving Medicare coverage.