bone density diagnosis

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How should the following be coded:
A patient is referred for a bone denisty screening 77081 for an osteoporosis screening
V82.81. During the exam she is found to have osteoporosis 733.90. How should this be coded...1st dx, 2nd dx?
One of our referring MD's is stating since we are not the treating physician we cannot put a diagnosis of osteoporosis on the claim only the screening.
I appreciate any feedback...thank you.
 
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If the physician has confirmed a diagnosis based on the the results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that prompted the ordering of the test may be reported as additional diagnosis if they are not fully explained or related to the confirmed diagnosis.

If the referring physician performed a diagnostic test for the referred symptoms and just happen to find another problem incidentally, he must code the incidental finding as the secondary diagnosis.
 
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mitchellde

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The guidelines clearly state that when the purpose of the test is screening then the screening V code is the 1st listed dx code. This would be for the performing as well as the interpreting provider. A screening is different from a diagnostic study in that for a diagnostic study you have a medical reason such as signs and symptoms or some other diagnosis that requires further study. A screening is performed on an asymptomatic individual that happens to meet predetermined criteria for the screening. As such there is no reason to suspect a positive finding or diagnosis, and screening is the medical necessity for the test, any findings here are incidental to the expectation that the patient is completely clean for that study.
 
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