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How would i code dx cpt 77080 DEXA or normal bone mineral density 77078??

she803

Networker
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The physician who documented impression of this report states normal bone mineral density but procedure states DEXA cpt 77080--need 2nd opinion on which cpt should i code and which dx should be coded b/c dx 627.8 was denied but i dont see any dx on this report indicating it. Please assist. Thank you.

Dual-Energy X-ray Absorptiometry:

History: 70 year-old woman who is being evaluated for osteoporosis.

Technique: Dual-energy x-ray bone densitometry of the lumbar spine and proximal right femur was performed.

The average bone density of L1 to L4 is 1.407 gm/cm2. This is 1.9 standard deviations above the mean for a young female control group (T-score), and is 2.6 standard deviations above the age, gender, and ethnicity matched control group (Z-score). Compared to previous examination, the bone mineral density has increased from 1.298 gm/cm2, representing 8.4 % improvement.

The left femoral neck bone density is 1.048 gm/cm2, which is 0.1 standard deviations above the mean of young female control group (T-score), and is 1.2 standard deviations above the age, weight, gender, and ethnicity matched control group (Z-score).


The right femoral neck bone density is 1.101 gm/cm2, which is 0.5 standard deviations above the mean of young female control group (T-score), and is 1.6 standard deviations above the age, weight, gender, and ethnicity matched control group (Z-score). Compared to previous examination, the bone mineral density has increased, representing 4.3 % improvement.


FRAX assessment for 10-year probability of fracture: major osteoporotic fracture 3.6 %, and hip fracture is 0.2 %.

Impression:

Normal bone mineral density of the lumbar spine and both proximal femurs. Improvement in bone mineral density compared to previous exam.
 

mitchellde

True Blue
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13,538
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Columbia, MO
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This looks like a screening and would need a screening V code. As to the 627.8 that is for a post-menopausal disorder and none is mentioned, you would use a V code for post menopausal status.
Being evaluated for the possibility of osteoporosis sounds like a screening to me. Without more documentation that is the only thing I can take from this.
 

berryc

Networker
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Fort Walton
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We would code this with 77080 and 77082 in my office. I would also use V code for screening V82.81. I hope this is correct and helps!
 
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