Radiology Coding Alert

Over the past few years, Radiology Practice have reported a significant increase in the number of bone density studies performed particularly DEXA (dual energy x-ray absorptiometry) scans. Although more and more scans are being ordered and being reimbursed coders need to remain aware of the restrictions Medicare and other payers place on the study and follow guidelines carefully.

DEXA scans have long been used to quantify bone density, detect bone loss, measure bone quality and diagnose osteoporosis. The reasons for their increased use are twofold: 1) the aging of the American population, and 2) increased recognition of risk factors contributing to osteoporosis and related conditions.

Carriers Disallow Screening Bone Density Scans

Traditionally, Medicare would not reimburse for DEXA 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]) as a screening device for patients concerned about osteoporosis, but required that medical necessity be demonstrated. This guiding principal has not changed, but the Health Care Financing Administration (HCFA) has modified its regulations to include a broader scope of diagnosis codes that support medical necessity.

I believe that one of the main reasons we are seeing larger numbers of DEXA scans has to do with the age of the female population, says Andrea Lamb, CPC, a billing and reimbursement specialist with St. Josephs Medical Plaza in Buckhannon, W.Va. The baby boomers have hit an age where they are beginning to go through menopause. They and their gynecologists are wondering whether to begin estrogen replacement therapy. Many would like to order a baseline bone density study so they can monitor their risk for osteoporosis.

Although their desire for a baseline study is understandable, she says, most carriers dont consider their concerns about possibly developing osteoporosis justification for a DEXA scan. In general, payers are looking for a definitive, clinical reason for the study to be performed, explains Lamb.

Definition of Medical Necessity Has Expanded

The clinical reasons that qualify as medical necessity have expanded in the past three years, thanks in part to studies released by the National Osteoporosis Foundation, says Deepa Malhotra, MS, CPC, coding and compliance manager for Healthcare Information Services Ltd., in Willowbrook, Ill., which provides billing services to more than 200 physicians throughout the Chicago metropolitan area. Their research has indicated that about 10 million individuals in the United States suffer from osteoporosis, she says. In addition to that, 18 million are considered to be at risk. I believe Medicare and other payers have realized over the past few years that there is a real medical need to provide bone density studies like DEXA.

When Medicare coverage of bone mass measurement was standardized under Section 4106 of the Balanced Budget Act of 1997, Malhotra notes, the local carrier in Illinois identified three primary ICD-9 codes that show medical necessity for DEXA scans: 256.2 (postablative ovarian failure), 256.3 (other ovarian failure) and 714.0 (rheumatoid arthritis).

Shortly thereafter, however, the local Medicare carrier reviewed and added codes for conditions that were considered risk factors for osteoporosis, like a family history of the disease, some long-term steroid therapies that affect bone mass and hyperparathyroidism, which affects the bodys ability to metabolize calcium, she says. By late 1999, that list had become quite extensive.

Nonetheless, the list of ICD-9 codes that constitute medical necessity varies greatly from one carrier to the next, and coders should check with their local payers for the latest list. Categories of conditions often included are:

Women who are estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings;
An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia (low bone mass) or vertebral fracture;
An individual receiving or expecting to receive glucocorticoid (steroid) therapy for more than three months;
An individual with primary hyperparathyroidism or specific other endocrine disorders; and
An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy.

Based on these descriptions, codes that may be covered are 733.00-733.09 (osteoporosis), 733.13 (pathologic fracture of vertebrae; collapse of vertebra), V58.69 (long-term [current] use of high-risk medication [for glucocorticoid therapy or FDA-approved osteoporosis therapy]), and 242.00-242.91(various thyroid conditions). Unless greater frequency is medically necessary, Medicare generally covers DEXA scans once every two years.

Although bone densitometry is not covered universally for males because some of the conditions justifying it are exclusively female in nature it is covered in other instances. One carrier in New England, for example, specifically cites postablative testicular hypofunction (257.1) and other testicular hypofunction (257.2) as diagnoses that represent medical necessity, in addition to the non-gender-specific conditions listed above.