Ob-Gyn Coding Alert

Effective July 1, 1998, bone mass measurements to screen women for signs of osteoporosis are now covered under Medicare Part B. But, like most Medicare reimbursement policies, this one has some important restrictions. Heres what practice managers and coders need to know to improve the likelihood of Medicare coverage, according to Transmittal No. AB-98-32 from the Health Care Financing Administration.

Tests must be performed with a bone densitometer, other than dual photon absorptionmetry (DPA), or a bone sonometer (i.e. ultrasound) device that has been approved or cleared for marketing by the Food and Drug Administration. The procedure must be furnished by a qualified supplier under the supervision of a physician.

Reimbursement will be paid only when the test is performed on a qualified individual who meets one or more of five medical indications. The indication that is most relevant to an ob/gyn practice is a woman who has been determined by a physician or qualified provider to be estrogen-deficient and at clinical risk for osteoporosis based on her medical history and other findings. Also pertinent is the medical indication for individuals receiving glucocorticoid therapy equivalent to 7.5 mg. of prednisone per day for more than three months.

Although it may appear that this indicator relates to breast cancer, according to Melanie Witt, RN, CPC, MA, program manager for the department of coding and nomenclature with the American College of Obstetricians and Gynecologists, Breast cancer does not come into play with these criteria. The prednisone requirement was put in to cover patients with arthritis who are taking the drug, which makes them more prone to osteoporosis.

The other medical indications relate to men or women with vertebral abnormalities, primary hyperparathyroidism, or who are currently on FDA-approved osteoporosis drug therapy.

Tests must be reasonable and necessary for diagnosing, treating or monitoring a qualified individual as defined above.

Tests must be ordered by a physician or a qualified non-physician provider treating the patient following an evaluation of the need for the bone density measurement.

Medicare coverage only permits bone mass measurement once every two years; however, if medically necessary, coverage may be available for more frequent tests. Medicare gives only two qualifying examples: 1) when the woman is taking prednisone for longer than 3 months, or 2) when the first scan was of a different type than will be used to monitor the patient from now on. Witt says that she is unaware of any other situations that would warrant Medicare payment for more frequent tests.

HCPCS Coding

Coding for these tests is as follows:

76075-Dual energy x-ray absorptiometry (DEXA), bone density study, one or more sites; axial skeleton (e.g. hips, pelvis, spine)

76076- Dual energy x-ray absorptiometry (DEXA), bone density study, one or more sites; appendicular skeleton (peripheral e.g. radius, wrist, [...]