DEXA BMD

PATIENT DETAILS

Title

First Name *

Last Name *

DOB *

Phone Number *

Medicare Card NumberInclude the first 9 numbers, without any spaces

Medicare Reference Number

Concession/Pension Card

Address

Street address

City

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SERVICES REQUESTED

Services referred (can select multiple): *

DEXA BMDQCT BMDBody Composition

DEXA BMD

For patients with NO PREVIOUS bone mineral density testing

Item 12320 - DEXA BMD for a patient over 70, initial scan, with no previous DEXA/QCT BMD - Once every 5 years

Item 12306 - DEXA BMD for a patient with a minimal trauma fracture - Can be used once in a 24 month period

Item 12312 - DEXA BMD for a patient with one of the clinical indications below - Once in a 12 month period
(a) prolonged glucocorticoid therapy (b) any condition associated with excess glucocorticoid secretion
(c) male hypogonadism (d) female hypogonadism lasting more than 6 months before the age of 45

Item 12315 - DEXA BMD for a patient with one or more of the following conditions - Once in a 24 month period
(a) primary hyperparathyroidism (b) chronic liver disease (c) chronic renal disease
(d) any proven malabsorptive disorder (e) rheumatoid arthritis (f) any condition associated with thyroxine excess.

DEXA BMD - Non-rebatable

For patients with PREVIOUS bone mineral density testing

Item 12306 - DEXA BMD for monitoring of low bone mineral density as defined below - Can be used once in a 24 month period
(a) Previous t-score: less than -2.5 (b) z-score: less than -1.5

Item 12306 - DEXA BMD for a patient with a minimal trauma fracture - Can be used once in a 24 month period

Item 12312 - DEXA BMD for a patient with one of the clinical indications below - Once in a 12 month period
(a) prolonged glucocorticoid therapy (b) any condition associated with excess glucocorticoid secretion
(c) male hypogonadism (d) female hypogonadism lasting more than 6 months before the age of 45

Item 12315 - DEXA BMD for a patient with one or more of the following conditions - Once in a 24 month period
(a) primary hyperparathyroidism (b) chronic liver disease (c) chronic renal disease
(d) any proven malabsorptive disorder (e) rheumatoid arthritis (f) any condition associated with thyroxine excess.

Item 12320 - DEXA BMD for a patient 70 years or older with previous BMD results as defined below - Once every 5 years
• The previous t-score for the patient’s bone mineral density is -1.5 or higher

Item 12322 - DEXA BMD for a patient 70 years or older with previous BMD results as defined below - Once every 24 months
• Previous t-score for the patient’s bone mineral density is between -1.5 and -2.5

Item 12321 - DEXA to monitor BMD at least 12 months after a significant change in therapy for low bone mineral density - Once every 12 months

DEXA BMD - Non-rebatable

QCT BMD

Patients with NO PREVIOUS bone mineral density testing

Item 12320 - QCT BMD for a patient over 70, initial scan, with no previous DEXA/QCT BMD - Once every 5 years

QCT BMD - Non-rebatable

Patients with PREVIOUS bone mineral density testing

Item 12320 - QCT BMD for a patient 70 years or older with previous BMD results as defined below - Once every 5 years
• The previous t-score for the patient’s bone mineral density is -1.5 or higher

Item 12322 - QCT BMD for a patient 70 years or older with previous BMD results as defined below - Once every 24 months
• Previous t-score for the patient’s bone mineral density is between -1.5 and -2.5

QCT BMD - Non-rebatable

BODY COMPOSITION

Total body composition only - Non-rebatable

Total Body Composition plus DEXA (tick appropriate DEXA item above)

Total Body Composition plus QCT BMD (tick appropriate QCT BMD item above)

Additional Clinical History (optional)

REFERRER DETAILS

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