Ob-Gyn Coding Alert

Ob/gyn coders who submit Medicare claims for DEXA bone scans (76075, dual energy x-ray absorptiometry [DEXA], bone density study, one or more sites; axial skeleton [e.g., hips, pelvis, spine] or 76076, dual energy x-ray absorptiometry [DEXA], bone density study, one or more sites; appendicular skeletal [peripheral] [e.g., radius, wrist, heel]) have often struggled to gain reimbursement for these claims. This is due both to Medicare restrictions on the need and frequency of the exams and limits in accompanying diagnostic codes to justify the scans. But with the addition of some new ICD-9 codes, effective Oct. 1, 2000, justifying a DEXA scan for women at risk for osteoporosis may be easier. As with all Medicare coverage, the ability to use new codes depends on carriers willingness to update their systems to use the newly available information, but the codes should make reimbursement for these tests less challenging.

Understand the Diagnostic Options

DEXA scans are used to screen for osteoporosis. Consequently, many Medicare patients, particularly women, receive this test and more women are undergoing the test than ever before. There is an increased awareness among physicians for the need to monitor bone loss in women, says Philip Eskew, MD, medical director of Womens and Childrens Services at St. Vincent Hospital in Indianapolis. In many cases, the test is the convincing reason for a patient to undergo estrogen replacement therapy when she may be reluctant to do so. DEXA scans enable physicians to track bone loss in a patient, as well as monitor the positive effects of estrogen therapy. The bottom line is that people are living longer, and they need to think about their lifestyle and steps to make the most of their later years, Eskew adds.

Justifying bone density studies has been difficult in the past. Most carriers have created lists of covered diagnoses that do not always correspond with the reason the patient is suspected of developing osteoporosis. Melanie Witt, RN, CPC, MA, an independent ob/gyn coding educator in Fredericksburg, Va., warns, however, that under Medicare coverage there is a big difference between performing a test to diagnose a problem versus routinely screening for a condition. The bone density study benefit is not for routine screening, she says. The physician must have documented that based on symptoms and/or medical history, the patient is at high risk for developing osteoporosis. The purpose of the scan is to confirm or eliminate this diagnosis. With many Part B and commercial carriers, the only diagnosis accepted with 76075 or 76076 was 781.9 (other symptoms involving nervous and musculoskeletal systems). This nonspecific diagnosis often resulted in rejected claims.

Now, however, 781.9 requires a fifth digit. Options include 781.91 (loss of height), 781.92 (abnormal posture) and 781.99 (other symptoms involving nervous and musculoskeletal systems). If, due to specific symptoms, a physician suspects but has not confirmed osteoporosis, one of these three codes should be used. The new codes should help clarify the medical necessity of bone scans to diagnose osteoporosis.

If the physician is considering hormone replacement therapy due to a patients menopausal status, he or she might first order a baseline bone density study to check for osteoporosis. In this case, the new diagnostic code V49.81 (postmenopausal status [age-related] [natural]) may be successfully linked to 76075 if the patient is naturally postmenopausal and not receiving hormones. Some carriers will also recognize V07.4 (postmenopausal hormone replacement therapy) if the patient is taking hormones. Each carrier has developed its own local coverage guidelines, so before billing a DEXA scan be sure to find out if the new diagnostic codes will be recognized by your carrier for an estrogen-deficient woman.

Prove Medical Necessity

Although Medicare will pay for a DEXA scan if the patient is menopausal or has an acceptable symptom like loss of height, it will do so only every two years and only for certain diagnostic reasons. Most carriers, including Medicare, dont consider the possibility of developing osteoporosis justification for a DEXA scan. Therefore, V82.81 (special screening for other conditions; osteoporosis) may be rejected as a diagnostic reason for testing (although practitioners hope there will be a loosening of this policy with the new code). Although the criteria for the biannual tests may vary somewhat between Part B carriers, the most common Medicare justifications for DEXA scans are as follows:

Estrogen-deficiency and clinical risk for osteoporosis, based on medical history and other findings;

Vertebral abnormalities as demonstrated by an x-ray to be signals of osteoporosis, osteopenia (low bone mass) or vertebral fracture;

Prescription use of glucocorticoid (steroid) therapy for more than three months;

Primary hyperparathyroidism or specific other endocrine disorders; and,

Monitoring the effectiveness of an FDA-approved osteoporosis drug therapy.

If a patient suffers from severe bone loss or related deficiency, Medicare may pay for the test more often than every two years.

When testing biannually or with greater frequency, preauthorization is often required. According to Maggie Hengst, CMM, practice manager of Ob/Gyn of East York, a nine-physician practice in York, Pa., most carriers she is familiar with require preauthorization for DEXA scans (done at a nearby radiology center) or for heel scans done in office.

Note: If the patient is sent to an outside facility for the DEXA scan, your office can bill for interpretation only. In this case, claims for 76075 or 76076 should be appended with modifier -26 (professional component). The radiology lab will in turn bill with the HCPCS/National Level II modifier -TC (technical component).

Have Patients Sign an ABN

Heel scans, using an Achilles express heel scanner, are administered as a preliminary measure. If a heel scan shows signs of osteoporosis, the office sends the patient to a radiologist for a DEXA scan. Even when we get pre-authorization, its not for a screening exam, Hengst warns. We must have a medical diagnosis of a possible symptom of osteoporosis to get paid for the scan. And because most commercial carriers follow Medicares lead, reimbursement is normally not better with non-Part B insurers.

Hengst says that although the list of acceptable diagnoses for DEXA and other bone scan screenings has grown, she has not yet seen an increase in reimbursement. In the meantime, she asks patients to sign an advanced beneficiary notice (ABN) in which they acknowledge that the bone scan (heel or DEXA) may not be paid under Medicare. As a courtesy to the patient, we will submit the claim to Medicare or any other insurer, but we tell the patient he or she will probably need to pay out-of-pocket if we are doing the test for screening purposes, she adds.

But theres reason to be optimistic. The new ICD-9 codes are a positive development, Eskew explains. They make it easier to provide insurers with a recognizable reason for doing the scan. He notes that poor descriptors prior to the new codes had made it difficult to prove this necessity, but the new codes will help improve accuracy in documentation. Coders who bill for bone density measurement scans should clearly state the patients diagnosis or osteoporosis risk factors on the claim.

We now have the correct diagnosis and rationale to say to the carrier, This is why we believe the test is justified, Eskew adds. Although Medicare and other carriers will ultimately decide whether to accept the new diagnoses, the codes enable providers to show the necessity of DEXA scans. The carrier has to decide whether it is concerned with the long-term health of the patient. If it is going to be providing her care for several years to come, then it is in the carriers best interest to keep the patient healthy. The new ICD-9 codes might ease restrictions and make DEXA scans more feasible for a greater number of women.

Note: For more information on the ICD-9 codes that constitute medical necessity for DEXA scans, check your Part B carriers manual or go to www.lmrp.net for a complete list of carrier rules.