Wiki DEXA/BMD scan: diagnosis question

[dsmith1025]

We do BMD's in our office. Our doctor interprets the scan and also dictates a report. We get referrals from other physicians for the BMD. The order for a male medicare patient states osteopenia. After doing the scan, there is no evidence that suggests osteopenia. Can we file the BMD with the diagnosis of osteopenia even though this patient does not have osteopenia?

 

[mitchellde]

No you cannot use a dx the patient does not have! Often a test is ordered as a screening and the the order will indicate the condition being screened for instead of screening... The question upon receipt of the order should be .. " why would they order a BMD if they know the pat has osteopenia?" if is is for screening the a screening V code is needed ,, if the patient does have opsteopenia and is undergoing treatment for the condition then the test is likely for drug monitoring and should be coded as therapeutic drug monitoring (see AHA coding clinics) V58.83 and long term drug, V58.69
But you are not to use a dx code for a diagnosis the patient does not have.

 

[dsmith1025]

We don't actually see the patients in our office so we have no idea if the patient is currently being treated for osteopenia. We only receive the order that states the patient's diagnosis. The order states osteopenia but the BMD was completely normal.

 

[mitchellde]

I understand but if you are the ones performing the test you need more information when you receive the order. You need to request a copy of the last office note or ask some questions. You cannot perform a test without all the correct information.. This is like a PT office receiving an order for rehab for a hip fracture which they know is incorrect. They need to know why, and this is what you need as well, why does a patient with opsteopenia require a BMD. Or is this a screening, and it matters to the patient!