Primary Care Coding Alert

DEXA, SEXA, CT: Use a unique code for each to firm up pay.

Paying attention to three details for your patients' bone density scans can make or break your claims' success. Follow our experts' advice regarding the types of tests, appropriate diagnoses, and acceptable timeframes, and you'll build strong claims and healthy bottom lines.

1. Report the Correct Type of Scan

Bone density scans (also known as bone mass measurements, or BMM) fall into five general categories. Your first step in coding is to determine the study type and site.

Ultrasound bone scan: You'll report 76977 (Ultrasound bone density measurement and interpretation, peripheral site[s], any method) when your FP completes a bone scan using ultrasound.

CT bone scan: For a CT bone scan, choose 77078 (Computed tomography, bone mineral density study, 1 or more sites; axial skeleton [e.g., hips, pelvis, spine) or 77079 (... appendicular skeleton [peripheral] [e.g., radius, wrist, heel]). "These are used together with computer software to determine the bone density, usually at the spine," says Sandy Swartz, manager of a central billing office in Sturgis, Mich. "CT is the most sensitive scan to detect bone disease and can take into account other diseases that might affect the bone, such as arthritis." CT bone scan also is the only commercially available technique to measure three-dimensional bone images.

DEXA scan: Choose from 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]), or 77082 (... vertebral fracture assessment) when your FP documents that he performed a DEXA or DXA scan. "A DXA scan measures the spine and often one or both hips. It's more sensitive and accurate than the CT at measuring small changes in bone density over time or in response to drug therapy," Swartz explains.

Radiologic scan: Code 77083 (Radiographic absorptiometry [e.g., photodensitometry, radiogrammetry], 1 or more sites) applies to radiologic scans.

SEXA scan: Your final category is the SEXA bone density scan. CPT doesn't include a code for SEXA scans, so turn to HCPCS Level II for G0130 (Single energy X-ray absorptiometry [SEXA] bone density study, one or more sites; appendicular skeleton [peripheral] [e.g., radius, wrist, heel]).

Before coding any of these or other similar tests, know your payer's guidelines and file accordingly. For example, Medicare considers 78350 (Bone density [bone mineral content] study, 1 or more sites; single photon absorptiometry) and 78351 (... dual photon absorptiometry, 1 or more sites) not medically reasonable and necessary. Any claim you send to Medicare with these codes is a denial just waiting to happen.

2. Check for Allowed Diagnosis

Medicare and other payers restrict coverage for bone density scans to certain diagnoses and conditions. According to Medicare, a qualified individual must meet at least one of these five indications:

Some contractors and payers might accept other diagnoses to justify bone density scans, so always check their guidelines. National Government Services (formerly Empire Medicare) lists 733.12 (Pathologic fracture of distal radius and ulna) as a diagnosis that might prove medical necessity. Highmark Medicare Services Inc. includes 246.9 (Unspecified disorder of thyroid) on its list of accepted conditions.

"The diagnosis used generally depends on if a fracture is involved, but will also include osteopenia," Swartz says. "We include an appropriate V code for patients over age 50 with osteoporosis related fractures." Possibilities include V13.51 (Personal history of other diseases; other musculoskeletal disorders; pathologic fracture), V13.52 (... stress fracture), and V15.51 (Other personal history presenting hazards to health; injury; traumatic fracture).

3. Verify You're Within the Timeframe

Turn to the calendar for your final checkpoint for successful bone density claims.

Here's why: Medicare will pay for bone mass measurements on qualified individuals every two years. "Every two years" means "at least 23 months have passed since the month" of the last bone mass measurement (Medicare Benefit Policy Manual, Chapter 15, Section 80.5.5).

"If you can document medical necessity on the patient, Medicare will allow you to bill within the two-year window but it must be medically necessary," advises Martha A. Conradson, administrator for Desert Bloom Family Medicine in Phoenix. "Otherwise, the two-year rule for all 'healthy' individuals is a good guideline to follow."

Two examples of when earlier tests might be necessary include: