Primary Care Coding Alert

Reader Questions:

See How Asymptomatic Patients are Still Eligible for This Screening

Published on Mon May 15, 2023

Question: My provider performed a bone density screening on a post-menopausal woman who has no symptoms of osteoporosis. If she doesn’t have symptoms, how do I report the encounter? Is she even eligible for the screening?

Michigan Subscriber

Answer: For encounters where the clinician performs a bone density screening, or bone mass measurements (BMM) on a woman who has reached menopause but is otherwise asymptomatic, you will report Z78.0 (Asymptomatic menopausal state) and Z13.820 (Encounter for screening for osteoporosis). If the patient is a Medicare beneficiary, she is likely eligible for the screening, and these codes support medical necessity for the screening itself. If the patient has other insurance, you may need to check with the payer in question regarding her eligibility for bone density screening.

Even though the patient may not have symptoms of the disease, the reason she is still eligible under Medicare can be found in the Medicare Benefit Policy Manual. The language in Chapter 15, Section 80.5.4 of the manual, which can be found at www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c15.pdf, says the following patients are eligible for BMM:

1. A woman who has been determined by the physician or qualified nonphysician practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings.

2. An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture.

3. An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than 3 months.

4. An individual with primary hyperparathyroidism.

5. An individual being monitored to assess the response to or efficacy of an FDA approved osteoporosis drug therapy.

Qualifiers 2 through 5 describe symptoms, but qualifier number 1 essentially supports the notion that post-menopausal women are automatically eligible. Medical history and other factors the provider calculates can contribute to the decision, but it’s universally accepted that women at this life stage have low estrogen and are at reasonable clinical risk for osteoporosis. Code Z78.0 is a Medicare-covered diagnosis for bone density studies such as 77080 (Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)).