Primary Care Coding Alert

Medical necessity and acceptable timeframes are must-haves before coding.

You could soon be coding for more bone density screenings, thanks to new recommendations from the U.S. Preventive Services Task Force (USPSTF) that might lower the age at which family physicians could begin screening some women for osteoporosis. Act now to ensure you're assigning the correct diagnosis codes and verifying medical necessity.

1. Know Osteoporosis, Osteopenia Differences

Many people think of osteoporosis when they hear the term "bone density screening." Osteoporosis -- which literally means "porous bone" --" is a disease characterized by low bone mass and structural deterioration of bone tissue. The changes lead to bone fragility and an increased risk of hip, spine, and wrist fractures. The condition is essentially a bone disease caused by dropping estrogen levels in postmenopausal women.

When your physician diagnoses osteoporosis, you'll select from code family 733.0x (Osteoporosis). Choose the diagnosis based on the patient's specific type of osteoporosis (such as postmenopausal, idiopathic, etc.). A less-thought-of diagnosis related to bone density screenings is osteopenia (733.90, Disorder of bone and cartilage, unspecified). Patients with osteopenia have lower than normal bone density.

Tip: Although osteopenia can be a risk factor or precursor for osteoporosis, not every patient with osteopenia develops osteoporosis.

Screening: Your physician will most likely order a dual-energy x-ray absorptiometry (DXA), which measures bone density, to diagnose the condition. DXA is the gold standard for measuring bone density, coder Donna Richmond with CodeRyte taught in The Coding Institute's audioconference "Surefire Bone Density Screening Strategies." Your code choices include:

• 77080 -- Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)
• 77081 -- ... appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
• 77082 -- ... vertebral fracture assessment.

2. Check for Documented Necessity

Medicare guidelines dictate that your documentation must include an order from a physician or qualified non-physician practitioner and an interpretation of the test results, Richmond says. Signing the machine printout doesn't count as an interpretation.

Physicians should also document a complete diagnosis for the patient. According to Medicare, a qualified patient must meet at least one of five indications:

• A woman who is estrogen-deficient, which is considered an ovarian failure (256.39, Other ovarian failure) and at clinical risk for osteoporosis
• An individual with vertebral abnormalities indicative of osteoporosis, osteopenia, or vertebral fracture (805.xx, Fracture of vertebral column without mention of spinal cord injury, or 733.13, Pathologic fracture of vertebrae)
• An individual on or expecting to receive glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg of prednisone, or greater, per day, for morethan three months (V58.65, Long term [current] use of steroids). Note that V58.65 should only be used as a secondary diagnosis.
• An individual with known primary hyperparathyroidism (252.01)
• A patient who needs monitoring because of osteoporosis drug therapy (such as V58.65).

"The diagnosis generally depends on if a fracture is involved, but will also include osteopenia," says Sandy Schwartz, a central billing office manager in Sturgis, Mich. "We include an appropriate V code for patients over age 50 with osteoporosis related fractures."

Example: Possible V code options could include V13.51 (Personal history of other diseases; other musculoskeletal disorders; pathological fracture) or V13.52 (... stress fracture).

3. Watch the Timeframe

Medicare pays for bone mass measurements on qualified patients every two years. The Medicare Benefit Policy Manual states that "every two years" means "at least 23 months have passed since the month" of the last bone mass measurement.

Exception: If you can document medical necessity for a patient, Medicare will allow you to bill for a bone density scan within the two-year window. Two examples of when earlier tests might be necessary include monitoring a patient who's been on glucocorticoid therapy for more than three months or needing a baseline measurement for a patient who had an initial test using a different technique than the one your physician wants to use for monitoring her (such as sonometry versus densitometry).

Final tip: Sometimes you might not know when the patient last had a DXA scan. If you aren't able to verify the date, ask the patient to sign an advance beneficiary notice (ABN) prior to testing.