Primary Care Coding Alert

Question: A 35-year-old woman presents with osteoarthritis of the knee and a pituitary abnormality. Her mother was also diagnosed with osteoporosis. Based on these factors, the doctor wants to perform a bone-density screening. How should we code?

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Answer: Medicare does not cover preventive screenings for osteoporosis unless the patient meets specific CMS standards. If the patient qualifies, CMS covers bone-density scans every two years. Many private payers follow CMS guidelines and apply the same rules for osteoporosis screenings. The regulations state that the physician must request the screening and that the patient must meet one of five criteria:
 
1. The patient is a woman who is estrogen-deficient and at clinical risk for osteoporosis, based on medical history and other findings.
 
2. The patient has vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass) or vertebral fracture (733.13).
 
3. The patient receives glucocorticoid (steroid) therapy of 7.5 or more milligrams of prednisone (J7506) per day for more than three months.
 
4. The patient has primary hyperparathyroidism (252.0).
 
5. The patient is being monitored to assess the response to any FDA-approved osteoporosis drug therapy.
 
In this situation, the patient may qualify under the first requirement. Use 253.x (disorders of the pituitary gland and its hypothalamic control) because this is the primary reason for the screening. The second diagnosis is 715.96 (osteoarthritis; lower leg) for osteoarthrosis of the knee joint. To help establish medical necessity, use V17.8 (family history of certain chronic disabling diseases; other musculoskeletal diseases) as the third code.
 
Link these diagnosis codes with the appropriate bone-density screening codes, 76070-76075, 78350-78351. These codes refer to "one or more sites," meaning studies of several sites in the same area should be reported as one unit of service. Physicians will usually test more than one site for a bone-density screening, but you can only report it as one unit. The diagnosis codes will establish the necessity of the screening and give you a better chance for ethical reimbursement.
 
Note: The Office of Inspector General listed bone-density screening as a target for investigations in 2002 and is examining the appropriateness of those billed to Medicare.
 
Answers to You Be the Coder and Reader Questions provided by Judy Richardson, RN, MSA, CCS-P, at Hill and Associates in Wilmington, N.C.; Carol Sissom, CPC, a senior healthcare consultant at Health Care Economics Inc. in Indianapolis; and Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians.