# screening dexa dilemma



## Lisa Bledsoe

Dexa is ordered as screening for osteoporosis (V82.81) and the report states findings as osteopenia (733.90).  Coded V82.81, 733.90.  Medicare does not pay for V82.81 as the primary dx - denies to patient responsibility.  Based on ICD-9 guidelines I think this is coded correctly.  Any other thoughts/comments??  Is there something I am missing?


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## cmcgarry

Lisa,

Medicare no longer has an NCD on DEXA scans, but instructions on who is covered, etc, are now in the claims processing manual.  Here is a link to just that section (scroll down to pages 13and on): http://www.cms.gov/transmittals/downloads/R70BP.pdf

They don't cover the V72.81 screening diagnosis - the conditions they cover are on page 15 of this document.

Hope this helps!


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## mitchellde

When a test is performed as a screening, then the screening V code is always listed first regarless of the findings.  This is stated in the coding guidelines.


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## cmcgarry

Yes, Debra is correct - and I meant to add that for a screening, the way it was coded was correct, and an ABN should have been obtained, explaining to the patient that a screening is not paid by Medicare.  Sometimes I hit send too early (or get interrupted and forget that I meant to say more!!)


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## Grintwig

Stupid semi-question here. Say that a patient is given a dexa scan as a screening for osteoporosis but they have other signs or symptoms...like pain. Is the screening code still supposed to be primary?
My docs do alot of colons and IMO if there is a rectal bleed or blood in stool I do not code for a screening. Should I be?


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## mitchellde

It depends on what the documentation states.  If the patient has a complaint of blood in stool and this is why the colonoscopy is ordered then it is not screening.  On the other hand if the patient has no complaint and the test is ordered as a screening then it is a screening, even if there is a history of rectal bleeding it is not the reason for the test.  If the dexa scan is ordered due to symptoms then it too is not a screening.  We must go by the documentation of what is the reason for the test.


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## Lisa Bledsoe

mitchellde said:


> When a test is performed as a screening, then the screening V code is always listed first regarless of the findings.  This is stated in the coding guidelines.



Agreed.  I was just getting some clarification to make sure I was on the right page.  These are going to patient responsibility.  I need to inform my docs that a screening dexa just isn't a Medicare benefit, which is really too bad.


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## Lisa Bledsoe

OK...I must be over-thinking this.  If the order states "post-menopausal screening for osteoporosis" how would you code this?  You can't just assume V49.81; but if you research the record and find that she is truly "asymptomatic postmenopausal (age-related)(natural), wouldn't you still code V82.81 first?  If she is asymptomatic then she is most likely not on HRT... so she is not "estrogen deficient"...My docs want to code V49.81, V82.81 and I think that's backwards.  I am going to pull my hair out on this one!!  Any advice is much appreciated!!!


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## Stefanie

I believe that most ladies over the age of 65 are postmenopausal, that doesn't necessarily mean the provider has determined that they are at clinical risk for osteoporosis ( I know that sounds crazy, but we can't assume right?)  I have encouraged my providers to state the specific reason why they believe the patient is at risk for osteoporosis, whether's it postmenopausal or they have symptomatic menopausal symptoms etc.  If they just state "due for dexa for osteoporosis screening" I don't use the V49.81, even if I can find that the patient is postmenopausal in the note, the provider didn't specifically state that was the reason for the dexa.   Below is a great pamphlet from Medicare for providers on Bone Mass Measurement.  It has helped me.  Hope it helps you.

http://www.cms.gov/MLNProducts/downloads/Bone_Mass.pdf


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## Lisa Bledsoe

Thank you Stefanie.
So, when your docs order screening postmenopausal, what order do you list the dx codes?


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## preserene

"Based on ICD-9 guidelines I think this is coded correctly."
Yes indeed.
*Screening is the TEST for disease or disease  Precursors IN SEEMINGLY WELL individuals so that early detection and management can be provided for those who test positive for the disease.*- *This is our Gold standard *Like other examples narrated (in  Diagnosis guidelines ), osteoporosis  can affect  anyone postmenopausal ( though  mostly, it does not occur immediate post menopause) and though some are soon affected and some later( the physician, the best judge, seeks for the test only when she decides the patient needs it; however the point to emphasize is this: the incidence  is higher in these group, though as postmenopausal number of years go up, the risk also goes up; of course, there are other Factors which make it faster for some.
 Health care expenditures in the United States that are attributed to osteoporotic fractures reach greater than $10 billion annually. *Detection of osteoporosis by screening can lead to early treatments that can maintain bone mass, lowering the risk of osteoporotic fractures* The Department of Health and Human Services' Health Care Financing Administration (HCFA) realized that the physician treating the beneficiary should be afforded flexibility and be given the option of ordering the most appropriate bone mass measurement for a patient in a particular set of circumstances.
With regard to estrogen-replacement therapy (ERT), HCFA recognized *the difficulty of trying to define the estrogen-deficient statutory category precisely*. Rather than attempting to define the category, HCFA left the determination of whether the patient is estrogen-deficient and at clinical risk of osteoporosis to the treating physician. This risk is calculated based on medical history or other findings.

After all the whole idea is to keep them fit which is their legitimate rights and at the age when they really has to depend incredibly on their OWNSELF, before they encounter an ‘attack'.

Here is my argument:
Well, while the career/payer accepts the screening for routine mammogram for women over 40, an amniocentesis for a pregnant women over 45, WHY NOT FOR POST MENOPAUSAL WOMEN, a screening for osteoporosis(all the more), at the time when the doctor feels  she needs it? ( Of course, you know, the doctors are not sitting there fancied and wasting their time to go for screening for  “not-in-need” cases.  Give them a fair chance to lead a healthy self-dependant  life.
Finally what I am trying to drive at is : You emphatically go for the Vcode 82.81 as the primary,on these points for validation: being postmenopausal, asymptomic, the encounter is for screening for osteoporosis and the physician decision and documentation for the order, and above all,  not the least, for the coders,our guideline's Principles.
If I were in your shoes, I would do that.
Thank you for your patient listening!


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## Lisa Bledsoe

*First of all - a HUGE THANK YOU to everyone who has posted on this thread!!!*

Second - what if the test is ordered as "screening for osteoporsis" but on the last dexa osteopenia was found.  I believe it should still be coded V82.81, 733.90 as that follows guidelines.  The only instance in which V82.81 would not be coded is if the provider ordered the dexa due to osteopenia...  

This is a huge deal, as all of these are going to patient responsibility.  We own the dexa and do the interp, so the global fee is being billed to the patient by our clinic.


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## preserene

The only instance in which V82.81 would not be coded is if the provider ordered the dexa due to osteopenia... 

I dont know why at all? The medical necessity do not support this;  osteopenia is just a step before the osteoporosis, meaning osteopenia is asort of a *forerunner* of osteoporosis.
Here is my stand:   Osteopenia is the thinning of bone mass. While this decrease in bone mass is not usually considered "severe", it is considered a very serious risk factor for the development of osteoporosis ,which is loss of bone mass.
 Bone mineral density (BMD) is the measurement of calcium levels in bones, which can estimate the risk of bone fractures. *It is also used to determine if a patient has osteopenia or osteoporosis.  *While osteopenia can be diagnosed using plain radiographs, the most common method for measuring BMD (and a way to definitively diagnose osteoporosis) is through Dual Energy X-ray Absorptiometry or DEXA.

Most people experience some loss of bone mass as they age, osteopenia and osteoporosis. Regular check-ups with a physician to monitor bone loss, especially in people over age 50., is one of the methods of  PREVENTION. *The measurements, known as T-scores, determine which category - osteopenia, osteoporosis, or normal - a person falls into*

Journal of the American Medical Association reported that a 50-year-old white woman with a T-score of -1 has a 16% chance of fracturing a hip, a 27% chance with a -2 score, and a 33% chance with a -2.5 score. *But there isn't a huge difference between, say, a -2.3 T-score and -2.5, although the former would be labeled osteopenia and the latter, osteoporosis. "*The label matters less than the number. These distinctions are to some extent arbitrary lines in the sand," says Dr. Maureen Connelly, a preventive medicine expert at Harvard Medical School. Regardless of your exact score, if you fall into the osteopenia category, your doctors will probably schedule you for a bone mineral density test every two to five years. 

This clip I presented not for arguement, but to have an idea that osteopenia does not make a huge defference in the pathological process and actually when osteopenia is confirmed it is the "fortune teller" /as a signal and merits the validity for doing DEXA.

Thank you for your time!


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## figdan45

*Coder Help*



Stefanie said:


> I believe that most ladies over the age of 65 are postmenopausal, that doesn't necessarily mean the provider has determined that they are at clinical risk for osteoporosis ( I know that sounds crazy, but we can't assume right?)  I have encouraged my providers to state the specific reason why they believe the patient is at risk for osteoporosis, whether's it postmenopausal or they have symptomatic menopausal symptoms etc.  If they just state "due for dexa for osteoporosis screening" I don't use the V49.81, even if I can find that the patient is postmenopausal in the note, the provider didn't specifically state that was the reason for the dexa.   Below is a great pamphlet from Medicare for providers on Bone Mass Measurement.  It has helped me.  Hope it helps you.
> 
> http://www.cms.gov/MLNProducts/downloads/Bone_Mass.pdf



should Code 627.9 be used with V82.81 or should I use V81.89 for DXA Bone Densitometry screening


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## figdan45

*Need Answer*



figdan45 said:


> should Code 627.9 be used with V82.81 or should I use V81.89 for DXA Bone Densitometry screening


should Code 627.9 be used with V82.81 or should I use V81.89 for DXA Bone Densitometry screening[/QUOTE]


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