Ob-Gyn Coding Alert

"My routine is to order the DEXA scan done at a facility, which then sends me the raw data," says Harry L. Stuber, MD, an independent gynecologist based in Cookeville, Tenn. He then reviews the data and prepares a report, billing 76075-26 (Professional component). The facility that performs the test reports 76075-TC (Technical component).
 
"I then have the patient back for a 10- or 15- (occasionally 25) minute face-to-face encounter in which I explain where she stands, how she compares to the 'ideal' 30-year-old woman (T score) and also to other women her own age (Z score)," Stuber says. For this visit, he bills 99212-99214 (Office or other outpatient visit for the evaluation and management of an established patient ).
 
But justifying bone density studies has been difficult because carriers have created lists of covered diagnoses that do not always correspond with the reason the patient is suspected of developing osteoporosis. The key to remember, however, is that DEXA scans are frequently a diagnostic test rather than a screening test. The physician must have documented that, based on symptoms or medical history, the patient is at high risk for developing osteoporosis.

Medical Necessity Remains the Key

According to section 4181.1 of the Medicare Carriers Manual (MCM), Medicare will pay for a bone mass measurement if the physician performs it on a "qualified individual." A qualified individual is a Medicare beneficiary who falls into at least one of the following medical categories:
 

Keep in mind, however, that you cannot use 627.2 if the patient is not having postmenopausal or climacteric symptoms. But ICD-9 goes on to define 627.2 to include "symptoms, such as flushing, sleeplessness, headache, lack of concentration, associated with the menopause." When an ob-gyn interviews a peri- or postmenopausal woman being considered for a DEXA scan, most will exhibit at least one of these symptoms, Stuber says. "That is usually my go-to diagnosis because most of my menopausal patients get headaches occasionally, forget things, have a little vaginal dryness or a hot flash."
 
Stuber goes on to clarify that a patient who is on hormones can still be "hormone deficient" if she is having symptoms. In fact, according to the American College of Obstetricians and Gynecologists' (ACOG) 2003 Compendium of Selected Publications, estrogen therapy "is the primary preventive and therapeutic modality for hypoestrogenic women with osteoporosis," he adds.
 
Unfortunately, only a handful of Medicare fiscal intermediaries and carriers agree with ACOG. Anthem Health Plans of New Hampshire, Associated Hospitals of Maine, Blue Cross Blue Shield of Rhode Island, and Cahaba Government Benefits Administrators recently added V07.4 to their list of justifying diagnosis for DEXA scans. Consequently, you should monitor other carriers' bulletins to see if they are willing to acknowledge this connection.
 
As for 256.2, using it would not be appropriate unless the woman's menopause is caused by surgery that removed her ovaries or radiation treatment that caused the ovaries to stop functioning. You can use an additional code with 256.2 to explain any symptoms the patient may have, according to ICD-9, but you aren't required to do so.
 
Similarly, the ICD-9 code for premature menopause (256.31) represents the cessation of ovarian function before the age of 40, while natural menopause is the result of declining ovarian function due to aging of the ovaries and usually occurs between 40 and 50 years of age, according to ACOG's Obstetric-Gynecologic Terminology. Because most Medicare patients have gone through natural menopause, 256.31 would be incorrect to use, coding experts say.

The Road Doesn't End at Estrogen Deficiency

 Other diagnosis codes that Medicare has stated will support DEXA scans include:
 

Although Medicare seems very clear regarding which diagnoses it will accept to reimburse DEXA scans, you should not assign an ICD-9 code merely because you know it will get your practice paid. You should always code based on the ob-gyn's documentation. To do otherwise would be fraudulent.
 
"I have seen people routinely code 'premature menopause' and always get paid," Stuber says. "But that diagnosis should only be used for those unusual cases in which it occurs before the age of 40, not for natural menopause." If you misuse this diagnosis, you could be faced with significant refunds in the case of an audit, he warns.
 
"Too often, I have clients tell me that because a patient has expressed concern about possible risk, they will list signs and symptoms even though the patient is not currently experiencing any symptoms," says Judith Richardson, RN, MSA, CCS-P, a senior consultant with Hill & Associates. "Given today's climate and Medicare's diligent search for fraudulent behavior, providers should never create a diagnosis where one does not truly exist."
 
Be sure to contact your insurance carriers to determine their accepted diagnoses for DEXA scans. Although Medicare has set certain parameters, payer rules may vary.