Orthopedic Coding Alert

A denial for one old code could cost you $100 per visit

If you find tracking Medicare's DXA claim restrictions on medical necessity and frequency a real chore, you-re not alone. But you can simplify the process and reduce denials by following this expert advice on keeping DXA claims airtight.

1. Make Sure You-re Using 2007 DXA Codes

For measuring bone density, dual-energy x-ray absorptiometry (DXA) is the gold standard, says experienced coder Donna J. Richmond, BA, CPC, RCC, quality assurance supervisor with CodeRyte, during The Coding Institute-s audioconference -Surefire Bone Density Screening Strategies.-
 
Pay attention: CPT 2007 changed the code numbers -- but not the descriptors -- for DXA.

Example: Your orthopedist orders an axial skeleton DXA for an estrogen-deficient female patient at risk for osteoporosis. You report 77080 for services performed on or after Jan. 1, 2007.
 
Rationale for change: Regrouping codes into different parts of CPT 2007 gives them a more logical location in the CPT manual, says Annette Grady, CPC, CPC-H, CPC-P, an independent coding consultant in North Dakota.
 
If you-re confused about all of the crosswalked codes, you should check out CPT 2007 Appendix M, Grady says. This -Crosswalk to Deleted CPT Codes- contains a list of all the crosswalked codes for this year.
 
Remember: Using the updated codes will save you from payment delays you don't need, considering Medicare pays roughly $100 for global code 77080.

2. Follow Those National and Local Rules

Documentation tip: Your documentation needs to include an order from a physician or qualified nonphysician practitioner and an interpretation of the test results (Medicare Carriers Manual, Part 3, Section 4181.1). Signing the machine printout doesn't count as an interpretation, Richmond says.
 
The physician also needs to document a complete diagnosis. Medicare doesn't offer a national list of covered ICD-9 codes, but it does state that an individual qualifies for coverage when she meets one of these conditions:
 - is estrogen-deficient and at risk for osteoporosis   (female only)
 - has been diagnosed by x-ray with osteoporosis,   osteopenia or vertebral fracture
 -  is receiving glucocorticoid therapy greater than or   equal to 7.5 mg of prednisone per day for more than   three months
 -  has primary hyperparathyroidism
 -  is being monitored for FDA-approved osteoporosis  drug efficacy.

Check your payer's local coverage determination (LCD) for the specific ICD-9 codes it says support medical necessity.
 
Example: National Government Services (formerly Empire Medicare) lists several diagnoses that may prove medical necessity, such as 252.01 (Primary hyperparathyroidism) and 733.12 (Pathologic fracture of distal radius and ulna).
 
The LCD also provides notes with certain ICD-9 codes, such as -code 793.7 [Nonspecific abnormal findings on radiological and other examination of body structure; musculoskeletal system] should only be reported when being used as a baseline for subsequent monitoring by another testing modality- (www.empiremedicare.com/
newypolicy/policy/l3141_final.htm).
 
Key: Only report the documented diagnosis -- never choose a diagnosis simply because you know you-ll get paid for it.
 
And you should always code results to the highest level of specificity, says Terry Leone, CPC, CIC, CMBS, coding specialist with Catamount Associates in New York.
 
Example: For the patient with primary hyperparathyroidism, you should report the five-digit code 252.01 rather than 252.0x (Hyperparathyroidism) or 252.x (Disorders of parathyroid gland).

3. Count Backward to Meet Frequency Requirement

Medicare will pay for bone mass measurements on qualified individuals every two years, Richmond says.
 
Translation: Every two years means -at least 23 months have passed since the month- of the last bone mass measurement (Medicare Carriers Manual, Part 3, Section 4181.2).
 
Medicare does offer exceptions to this frequency rule, Richmond says. Payers may consider more frequent DXA scans when medically necessary under either of these circumstances, she adds:

 - you-re monitoring a patient on glucocorticoid therapy  for more than three months
 - you need a baseline measurement to monitor a patient  who had an initial test using a different technique (such as sonometry) than the one you want to use to monitor the patient (such as densitometry) (Medicare Carriers Manual, Part 3, Section 4181.2).

Tip: Payers aren't limited to these frequency exceptions. Check your LCDs for your payers- specifics, Richmond says.