# Radiology coding question -bonemineral density



## harshila (Aug 2, 2010)

hi everyone 

pt came for bonemineral density of the spine and hip testcpt code 77080
dr wrote on script v82.81 and 733.00
radiology report imp say pt has osteopenia
i use adimit code v82.81(screnning for osteoporosis)
i use primary code v82.81 and 
secondary code 733.90(osteopenia) and medicare denied any one has better
soulation for this senior how i code this chart or any website i can go for screnning guideline 


please help me
thanks


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## Grintwig (Aug 2, 2010)

Does your physician perform the test and interpet the results or just interpret the results. 
If your office doesn't actually perform the test you need to be billing 77080-26. Just a thought without knowing why you are being denied it's hard to say what needs to be corrected.
What does that denial say as the reason that you are not being paid?


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## harshila (Aug 3, 2010)

thanks 

i am coding for hospital outpt radiology test is perfrom at hospital in radiology dept medicare denied because i put primary dx v8281.


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## rryder1963 (Aug 3, 2010)

*V82.81*

V82.81 is a Screening code and I beleive there is a NCD on CMS's website for DEXA scans as patients must meet specific criteria for reimbursment there might also be specific time-frames involved. Even it is retired, it's always a good idea to reference these if one exists for a particular CPT code.  If the patient has known osteoporsis and is on medication for the condition, why the V82.81 because at this point and time I don't think it would be considered a screening but more of a follow-up to treatment for a known condition (733.00 osteo and V58.69 chronic use of high-risk medication).

Check the CMS website to make sure.


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## Grintwig (Aug 3, 2010)

The 733.90 primary on the scan should pass it per the Medicare LCD's.


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## Tonyj (Aug 5, 2010)

harshila said:


> hi everyone
> 
> pt came for bonemineral density of the spine and hip testcpt code 77080
> dr wrote on script v82.81 and 733.00
> ...



I'm assuming you work at a diagnostic facility since you stated "pt came for bone mineral density..." That being said, you always code the primary diagnosis from the impression of the Rad report. Being an outpt diagnostic facility allows you to also code from the findings. If the findings are negative or inconclusive then you would code the signs and symptoms.

It's been my experience that medicare won't pay for certain v codes, v82.81 is one of them in my region. You must check medicares LCD in your region. To my knowledge they do pay 733.00 as well as v58.65 and v58.69 with accompanying documentation. Again you must check with your local MCR office. 

 Just a suggestion try re-billing w/o the v code or use another vcode (2ndary)to show the use of steroids or hormonal replacement therapy if so documented.

Also you can try this website for medicare.   

http://www.ngsmedicare.com

Hope this helps

Tonyj


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## Radcoder1313 (Aug 5, 2010)

Do not remove the screening as your primary diagnosis or you are failing to follow coding guidelines.  If a DEXA is ordered as a screening, it must be coded as V82.81 and the osteopenia or osteoprosis can be the secondary code.

This is where the importance on an ABN would come into place!!


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## Tonyj (Aug 6, 2010)

Please review Coding Guidelines Section IV chapter L (patients receiving diagnostic test only)"....code any confirmed or definitive diagnosis documented in the interpretation...."

I stand by what I said. Try rebilling with the primary diagnosis as 733.00 after you've checked with medicare's LCD

Tonyj


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## Chanke (Aug 6, 2010)

Medicare won't cover a screening code.  The pateint MUST have one of the following criteria for Medicare coverage of a DEXA:

256.9  ovarian dysfunction
733.90 osteopenia
733.00 osteoporosis
737.30 Scoliosis

other indicators that would be considered by MCR include vertebral abnormalities demonstrated by Xray to be indicative of osteoporosis, osteopenia, or vertebral fracture; an individual receiving glucocorticoid (steriod) therapy equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than 3 months; An individual being monitored to assess the respone to or efficacy of an FDA-approved osteoporosis drug therapy. 

That being said, if the phsyician writes the order with the screening code, you have to code it that way.  Our facility has a standardized DEXA specific order sheet that is used, specifically when the patient has clinical indicators for bone density problems and we don't get dinged for the screening issue by using it.  

If it is truly just a screen, then the doc writes that order out seperately indicating that it is simply a screen, and we have the patient sign an ABN for it.

Hope that helps.

Hope that helps.


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## mitchellde (Aug 6, 2010)

Tonyj said:


> Please review Coding Guidelines Section IV chapter L (patients receiving diagnostic test only)"....code any confirmed or definitive diagnosis documented in the interpretation...."
> 
> I stand by what I said. Try rebilling with the primary diagnosis as 733.00 after you've checked with medicare's LCD
> 
> Tonyj



Yes but the guidelines also state that when the reason for the exam is screening then screening remains the first-listed dx.  The section you are quoting is for diagnostic tests and a screening test is not a diagnostic it is screening.  The screening V code must remain primary.  If the patients plan states that screening is non covered then I do not need an LCD the patient can be held responsible.
We CANNOT change the scenario with dx codes JUST TO GET THE INSURANCE TO PAY A CLAIM!  If it is screening then you have coded it correctly with the V code first.  Bill the patient.  If the patient is on phosamax and this test is to monitor the medication then you use V58.83 first then the V58.69 second, this is per coding clinics.


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## Lisa Bledsoe (Aug 6, 2010)

harshila said:


> hi everyone
> 
> pt came for bonemineral density of the spine and hip testcpt code 77080
> dr wrote on script v82.81 and 733.00
> ...



I'm curious as to why the request states screening for osteoporosis and also osteoporosis for the diagnoses...Does this patient have osteoporosis to begin with?  I would look for previous DEXA scans first.  We see this with our rheumatology pts, where the osteoporosis is actually reversing into osteopenia because of treatment.  But if she has osteoporosis this cannot be a screening DEXA.


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## Tonyj (Aug 6, 2010)

Chanke said:


> Medicare won't cover a screening code.  The pateint MUST have one of the following criteria for Medicare coverage of a DEXA:
> 
> 256.9  ovarian dysfunction
> 733.90 osteopenia
> ...



I urge you to review ICD9's, Coding Guidelines, Section IV (L) "Patients receiving diagnostic services only". You may save your patients from being unduly billed. An ABN will provide your practice with the right to bill the patient if the procedure is deemed not covered by medicare due to the diagnoses. BUT if the report is positive then you should be billing medicare with the primary diagnosis of the impression and if that diagnosis is covered by medicare you will be reimbursed accordingly AND your patient won't be subjected to undue fees from your facility.

Hope this helps!

Tonyj


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## mitchellde (Aug 6, 2010)

I had the same question, the original order was a little strange which is why I brought up drug monitoring as a possibility.  It is just so hard to tell from the info provided, unfortunately we can look at previous info but we cannot use that info for our coding of this encounter, but we can use it to write really good queries to the physican.


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## mitchellde (Aug 6, 2010)

Tonyj said:


> I urge you to review ICD9's, Coding Guidelines, Section IV (L) "Patients receiving diagnostic services only". You may save your patients from being unduly billed. An ABN will provide your practice with the right to bill the patient if the procedure is deemed not covered by medicare due to the diagnoses. BUT if the report is positive then you should be billing medicare with the primary diagnosis of the impression and if that diagnosis is covered by medicare you will be reimbursed accordingly AND your patient won't be subjected to undue fees from your facility.
> 
> Hope this helps!
> 
> Tonyj



JUst to be clear Tonyj, a screening test is not the same as a diagnostic test.  If the test was ordered as a screening then that is how we must bill it and the patient may in fact be responsible for the bill.  We cannot change the dx to the impression if the test is screening.  We can do that on a diagnostic test.  The definition of diagnostic is the test is being performed because the patient has some signs or symptoms, indicator if you will that we need to examine for further information or definitive dx.  As screening is performed for a patient that is asymtomatic but may be at risk given certain factors or age or genetics.  A finding on a diagnostic study is what we were looking for so we may change the dx from the symptom to the finding, a finding other than normal on a screening test is not what is expected and is incidental to the epectation and incident dx are listed as secondary dx.  Again do not use the guideline for diagnostic studies and apply it to screening tests.


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## Tonyj (Aug 6, 2010)

mitchellde said:


> JUst to be clear Tonyj, a screening test is not the same as a diagnostic test.  If the test was ordered as a screening then that is how we must bill it and the patient may in fact be responsible for the bill.  We cannot change the dx to the impression if the test is screening.  We can do that on a diagnostic test.  The definition of diagnostic is the test is being performed because the patient has some signs or symptoms, indicator if you will that we need to examine for further information or definitive dx.  As screening is performed for a patient that is asymtomatic but may be at risk given certain factors or age or genetics.  A finding on a diagnostic study is what we were looking for so we may change the dx from the symptom to the finding, a finding other than normal on a screening test is not what is expected and is incidental to the epectation and incident dx are listed as secondary dx.  Again do not use the guideline for diagnostic studies and apply it to screening tests.



While I respect your views Michelle, as I have been following your comments on numerous occasions, I'm still in a bit of disagreement with you and the other comments. 

It is understood that this is a screening exam but outpatient diagnostic facilities do have a bit of leeway when billing screening as well as other exams especially when they are deemed positive. e.g. screening mammograms can become diagnostic dependent upon the impression and the outpatient facility can bill as such. I've been in an outpatient diagnostic facility for 10 years and we've researched these same scenarios countlessly by going through numerous avenues of advice. I'm am in no way trying to give false or misleading advice. That is not to say that my experience may be flawed in some areas but I feel confident that I'm giving the most current advice I have on the subject of outpatient diagnostic services.

Respectfully,
Tonyj


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## mitchellde (Aug 6, 2010)

where is it written that outpatient diagnostic facitilities have any leeway with coding the diagnosis for the reason for the encounter?  This is not written in the guidelines at all.  You have quoted correctly for diagnostic studies, what I am pointing out is that a screening is not a diagnostic study.  There is no leeway with the patient's diagnosis.  The diagnosis belongs to the patient and the reason for a screening is not the finding it is screening.  I worked in an outpatient diagnostic center as well and we always coded screening.  And it is misleading to code a screening as diagnostic and to instuct others to do so.  You are misleading the payer into paying something that should have been patient responsibility.  And you are communicating incorrect information regarding the patient's status.  The patient was asymptomatic when it is screening and was following prudent preventive protocol to have screening prformed.  when you do not code it as such then you are communicating the incorrect thing,  You are showing a patient that was symptomatic had a test and found that they did in fact have osteopenia.  You are setting the stage for the possibility of a pre exisisting condition for the patient which can cause bigger issues down the road.
I have big big issues with incorrect diagnosis coding.  I know you feel you are correct, I am only asking that you stop and think about it real hard. screening is NOT the same thing as diagnostic so you cannot cross those rules over.


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## rmickalich (Aug 7, 2010)

*Dexa 77078*

Per Medicare, they will cover this test once every two years.  Medicare considers this CPT a diagnostic code, so I wonder if it was actually meant for a screening.  

In the past, the hospital that I worked at had used the wrong CPT code for the screening and ran in to the same problem of not getting it covered.  At the same time, physicians were not aware that Medicare patients are covered every two years; rather than yearly.  To code the service, the coders would go by what is documented in the chart as to why it was actually ordered, so if it was meant to screen for osteoporosis than obviously a V-code needs to be primary.

In my opinion, facilities are going to have to use the ABN process if there is a problem.  That was one of the biggest issue where I worked at.

NCD: 
http://www.cms.gov/MCD/viewncd.asp?...et=ncd:150.3:2:Bone+(Mineral)+Density+Studies


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## Kimberley (Aug 11, 2010)

*Bone density dx ?*

What if order states ROUTINE, scan is NORMAL and pt history states pt is post-menopausal???


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## mitchellde (Aug 11, 2010)

Sounds like screening to me.  This is done routine as a screening for patients that are post menopausal.  There are no symptoms or problems expressed by the patient nor the physician.  This is the essence of the difference between a screening and a diagnostic test.  A diagnostic test is performed to try and find the reason for symptoms or issues, it is inherently investigative by nature.  A screening is performed as a surveillance because a patient meets certain risk requirements.  A finding on a screening exam does not make it a diagnostic.  The findings are incidental and will be investigated at a future encounter.


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