Reporting DEXA Demands Attention to Detail

Reporting DEXA Demands Attention to Detail

Dig deep to determine location and reason for imaging when coding for DEXA scans.

Have you ever wondered why we get smaller as we age? From age 25 to 50, the average adult stays at a stable bone density. Once we hit 50, our bodies lose around one percent of their bone mass each year. In fact, women can lose up to 20 percent of their bone density after menopause!

This progressive bone loss increases the risk of fractures and is one of the primary reasons it is so important to schedule a bone scan when recommended. A bone densitometry test — dual-energy X-ray absorptiometry (DXA or DEXA scan) — measures bone mineral density (BMD) and is key to detecting osteoporosis, or loss of bone mass, which can lead to a variety of medical problems. Let’s take a closer look at DEXA scans, how to report them, and how to avoid coverage denials.

Determine Central vs. Peripheral

A DEXA scan is a high-precision type of X-ray and a non-invasive way to measure and track BMD, diagnose osteoporosis, and assess a patient’s risk of bone fracture. There are two types of DEXA:

Central DEXA: The majority of DEXA scans are central, which focuses on the lower spine and hips. The patient is positioned on their back on a table above an X-ray generator with their legs propped on a padded box. The technician then steps out of the room and takes the images of the spine and hips. The CPT® code for a central DEXA is 77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine).

Peripheral DEXA: Peripheral imaging focuses on the extremities such as the wrist, finger, leg, or heel. The CPT® code is 77081 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel).

When a vertebral fracture assessment is done, turn to these DEXA codes:

77085   Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment

77086   Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA)

These CPT® codes have a Medically Unlikely Edit of 1, meaning only one unit can be billed per date of service. Note the code descriptors that state “bone density study, 1 or more sites.” This means that, for example, central DEXA scans of the hips, another part of the pelvis, and the spine is one unit when performed on the same day of service.

Tip: Go to these codes in your CPT® code book and highlight in the descriptors “axial skeleton” and “appendicular skeleton,” along with the appropriate body sites. For 77085, highlight “including a vertebral fracture assessment.”

Interpret the Report

DEXA scores are reported as T scores and Z scores:

T score compares the patient’s body mass index with that of a healthy 30-year-old of the same sex.

Z score compares the patient’s body mass index with that of an average person of the same age and sex. It is similar to when you take your child to their checkup and the doctor gives you a percentile of how the child compares to other children within the same reference.

While CPT® code descriptors indicate otherwise, your axial skeleton is made up of the bones in your head, neck, back, and chest. Your appendicular skeleton is made up of the bones that attach (append) to your axial skeleton — the bones in your shoulders, pelvis, and limbs (arms, hands, legs, feet).

The lower the score, the lower the bone density.

  • T score of -1 to +1 is considered normal.
  • T score of -1.1 to -2.4 indicates osteopenia (low bone mass). This means a person has already started to lose bone mass and is at increased risk for fracture. Osteopenia is a precursor to osteoporosis and serves as a warning that the patient should take steps to strengthen their bones.
  • T score of less than -2.5 is considered osteoporosis. This means the patient is at high risk of fracture. The doctor will help the patient devise a program that may include medication and lifestyle changes.

Generally, all DEXA reports look the same, with the report showing the images that were taken, along with a graph with portions that are green, yellow, and red. The graph reflects the regions that were scanned and is scored from a +2 to a -5, as shown in the figure below.

DEXA densitometry report of left femoral scan; diagram and curve of values ​​used to investigate osteoporosis in menopausal women

Normal bone density (the green section) is -1 to 2. Low bone mass (the yellow section) is -1 to -2.5, and osteoporosis (the red section) is -2.6 to -5. The numbers on the left indicate BMD and let the provider know the T and Z scores.

Append a Modifier, When Appropriate

The following modifiers may be appended to DEXA CPT® codes:

  • Modifier 26 Professional component – Used when the physician performs the service in a hospital, does not own the equipment used in DEXA studies, or is an employee in a facility.
  • Modifier TC Technical component – Reported by the hospital that owns the equipment.
    • Globally billed means there is no modifier used, as the physician owns the practice and equipment.
  • Modifier 53 Discontinued procedure – Used if a physician terminates the procedure due to unavoidable circumstances and plans to repeat the procedure in the future. An example of when this modifier would be used is in the case of power going out in the middle of the scan.
  • Modifier 52 Reduced services – Used when the physician does not complete the procedure and they do not plan to repeat it.
  • Modifier 59 Distinct procedural service – Used when there is more than one DEXA scan performed on the same date of service such as a DEXA of the hips and a DEXA of the radius. Codes 77080 and 77081 may be billed on the same day with modifier 59 or modifier XU Unusual non-overlapping service depending on payer.
  • Modifier Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician; or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area – HCPCS Level II modifier used when a technician or physician is on leave and there is a substitute.

Prove Medical Necessity

Insurance covers DEXA scans that are shown to be medically necessary. For women over the age of 65 and men over the age of 70, a DEXA scan is considered medically necessary, and Medicare will cover a DEXA scan every two years. For a postmenopausal woman under the age of 65 or a man 50-69 years old, a DEXA scan may be covered if the patient has risk factors. Risks include low calcium, high-risk medication use, family history of osteoporosis, diseases or conditions associated with bone loss, history of bone fractures, removal of ovaries, and small/thin frames.

See the Resources section for a list of FDA-approved drugs for the treatment of osteoporosis.

Avoid Claim Denials

The main reason a DEXA scan is denied is because the payer does not consider it to be medically necessary. Make sure to check with your payer to verify what they consider to be medically necessary. The Centers for Medicare & Medicaid Services article 56484 provides a list of medically necessary ICD-10-CM codes for these services.

The global period may also play a role in coverage denials. If the DEXA scan is for screening purposes and is billed more than once every two years, a global period denial would be valid.

Lastly, look out for denials related to using ICD-10-CM code Z13.820 Encounter for screening for osteoporosis as a standalone code. Even though Z13.820 is self-explanatory and stands for exactly what the DEXA is for, Medicare will immediately deny it if used on its own. The payer wants additional codes to be added to provide information about why the DEXA is being performed (for example, monitoring drug therapy or identifying the patient as a postmenopausal woman). You could also use an ICD-10-CM code with Z13.820 to provide information about the DEXA report findings.

Now that you understand the nuances of DEXA scans and how to report them, you can help your practice avoid coverage denials and lost revenue.


Resources

www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=56484&ver=17

FDA-approved treatments for osteoporosis: https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/34639_24/L34639_MS004_BCG.pdf

carlsbadimaging.com/bone-densitometry-dexa-scan

ericaleon.com/2021/06/12/strategies-strong-bones

Medical coding books

Grabiela Juarez
Latest posts by Grabiela Juarez (see all)

About Has 1 Posts

Grabiela Juarez, CPC, CPMC, COC, AAPC Approved Instructor, has over 10 years in the medical field and is the owner and founder of Medical Coding Vida Academy. She has a strong background in revenue cycle management. Juarez has a passion for teaching and is currently serving as the 2022 president of the Salt Lake City, Utah, local chapter. You can reach her at grabiela@mcvacademy.com.

Leave a Reply

Your email address will not be published.

Have you used AAPC's member discount savings program (e.g., travel, entertainment)? (On top menu: Resources/Other Resources/Savings Center)