Wiki Osteopenia/Osteoporosis coding

[peytonxx3]

A patient has been dx with Osteoporosis and has treatment authorized (Prolia) specifically for Osteoporosis. During the course of treatment, the doctor downgrades the dx to Osteopenia because treatment is working, but the same treatment is being continued.

Do I still code the Osteoporosis as well as the Osteopenia? The current treatment does not cover Osteopenia as the authorized dx.

The new office notes only list the Osteopenia.

I guess my question is, does Osteoporosis go away, or are we still treating the Osteoporosis that is now Osteopenia due to success in treatment?

 

[Amy Pritchett]

In my opinion, the physician is still actively treating the osteoporosis and should not have documented the osteopenia. The osteopenia is a lower-level of the osteoporosis, however if the patient was taken off the medications, would this transition back up to osteoporosis? I would query your physician as to the effect of the medication on the disease.

Hope this helps