Primary Care Coding Alert

Midyear switch means about 1 RVU more for bone density study. According to a recent CMS communiqué, FPs who provide certain bone density studies will be getting a retroactive reimbursement bump; there will also, however be a slight degradation of the Medicare conversion factor beginning on June 1. The $kinny: CMS is only changing the conversion factor from $36.0846 to $36.0791, states CMS Transmittal 700, published May 10. Medicare administrative contractors (MACs) will use this conversion factor to calculate your payments after May 31. The transmittal failed to address the 800-pound gorilla in the room, however the 21 percent pay cut FP practices are scheduled to face on June 1. (At press time, Congress had not addressed the pay cut. Check out the next issue of Family Practice Coding Alert to see how it all shakes out.) Silver Lining: More Cash for DEXAs The transmittal contained some very good news for FPs who perform dual-energy x-ray absorptiometry (DEXA) scan imaging (77080, Dual-energy X-ray absorptiometry [DXA], bone density study, 1 or more sites; axial skeleton [e.g., hips, pelvis, spine]). The new transitioned non-facility relative value units (RVUs) for 77080 are 2.70; the year's initial fee schedule listed 1.71 RVUs for this scan. When combined with the conversion factor of $36.0791, that makes DEXA pay about $97 per encounter, a $36 increase over the pre-revision total of about $61. Know Your DEXA Eligibility Requirements According to experts, you ignore Medicare's bone density scan requirements at your own peril. Learn the Medicare guidelines so you don't miscode even once, recommends Kent J . Moore, manager of healthcare delivery and financing systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan. Straight from the source: Moore says there's no better source than the Medicare Guide to Preventive Services for information on eligible patients. The manual reports that bone mass measurements are indicated for:

• "A woman who has been determined by the physician or qualified non-physician practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings;
• "An individual with vertebral abnormalities, as demonstrated by an X-ray to be indicative of osteoporosis, osteopenia (low bone mass), or vertebral fracture;
• "An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than three months;
• "An individual with known primary hyperparathyroidism; or
• "An individual being monitored to assess the response to, or efficacy of, an FDA-approved osteoporosis drug therapy."

Impact: "An FP might encounter any or all of these types in his or her practice," explains Moore. (For more information on bone density studies and their reporting guidelines, see http://www.cms.gov/MLNProducts/downloads/mps_guide_web-061305.pdf.) Check Frequency Guidelines Next "If an individual fits one of the five categories above, then Medicare will generally cover bone mass measurement once every two years. If medically necessary, Medicare will cover bone mass measurement more frequently," says Moore. Examples of situations where more frequent bone mass measurements may be medically necessary include, but are not limited to, the following medical conditions:

• Monitoring patients on long-term glucocorticoid (steroid) therapy for more than three months.
• Allowing for a confirmatory baseline bone density study to permit monitoring in the future if certain specified requirements are met.
• Dx code alert: Each 77080 claim must contain "a valid ICD-9-CM diagnosis code obtained from the lists of diagnosis codes for the screening benefit's categories that indicate the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy," reminds Moore.

Medicare contractors will maintain a local list of valid codes for the benefit's screening categories, meaning "coders need to check with their local Medicare contractor for a list  of diagnosis codes that satisfy medical necessity for these services," advises Moore Get an ABN to Be Safe Don't forget about the frequency rules for DEXA coverage. In some cases, you may not know when the patient last had a DEXA scan. In these cases, "I would, along with the patient, make the call to Medicare to see if we could find out if or when there was a previous DEXA," says Kim French, CIC. If you cannot locate the date of the previous DEXA scan, ask the patient to sign an advance beneficiary notice (ABN). Fallout: "Absent a signed ABN, if Medicare denies the service for medical necessity or frequency, the patient cannot be held responsible and the FP's office will be left holding the bag for the cost of the service," warns Moore The 77080 pay boost is retroactive to Jan. 1, 2010, according to CMS. For more information on DEXA payment and the conversion factor, visit www.cms.gov/transmittals/downloads/R700OTN.pdf.