Radiology Coding Alert

Avoid these 3 errors to improve your chances of bone scan reimbursement.

While assigning the correct dual-energy X-ray absorptiometry (DXA) code may appear to be straightforward, this is a service that payers watch and may request records for. If providers submit incorrect or insufficient documentation or perform the procedure without meeting coverage conditions, your practice could see claim denials.

Choose the Correct DXA Scan Code Based on Body Area

DXA scans help providers determine a patient’s fracture (bone break) risk. Providers use the DXA scans to diagnose several bone-related health problems, such as osteopenia and osteoporosis.

The CPT^® code set includes various codes related to DXA. The focus here is on two codes, each of which is dependent on the body area the provider scans. You’ll assign 77080 (Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)) if the provider performs a DXA scan on a bone site on the axial skeleton. However, if the radiologist performs a DXA scan on appendicular skeleton sites, such as the wrist or heel, then you’ll assign 77081 (… appendicular skeleton (peripheral) (eg, radius, wrist, heel)).

Payers may have different preferences regarding which conditions support medical necessity for DXA scans on the different body areas. Because of these strict coverage rules, payers may request additional documentation to support payment. Here are three errors to watch for when you get that request.

Error 1: ADRs Receive No Response

If a claim for 77080 or 77081 is selected for review or more documentation is needed to complete the claim, your practice may receive an Additional Documentation Request (ADR) letter. After the local Medicare Administrative Contractor (MAC) generates the letter, your practice needs to submit the requested documentation within 45 days from the date of the ADR, according to Noridian Healthcare Solutions, during the Part B MAC’s Jan. 26, 2022, webinar, “Dual-Energy X-Ray Absorptiometry (DEXA) Scan - Medical Review Top Errors.”

A simple way to correct or avoid this error is to ensure the ADR letter is forwarded to your practice’s medical records department or appropriate personnel. The request is time sensitive and should be addressed before the 45-day period lapses.

Medicare contractors are instructed to deny claims when the requested records are not submitted following an ADR. According to the Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, “If information is requested from both the billing provider or supplier and/or a third party and no response is received within the expected timeframes (or within a reasonable time following an extension), the MACs, [Recovery Audit Contractors], [Supplemental Medical Review Contractors], and [Unified Program Integrity Contractors] shall deny the claim, in full or in part, as not reasonable  and necessary” (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf).

What documentation should you submit? “The documentation that should be submitted with an ADR includes the DXA assessment and report that sustains the medical necessity for the test, as well as the order from the physician or qualified nonphysician practitioner,” says Grabiela Juarez, CPC, CPMA, COC, revenue cycle specialist of Sceptre Management in Salt Lake City, Utah. Practices can also submit documentation showing a DXA scan performed within two years, as well as previous medical records that show a history of osteoporosis, X-rays for recent fractures, or long-term drug therapy for more than three months, Juarez adds.

Error 2: Submitting Incomplete or Insufficient Documentation

Incomplete or insufficient documentation includes:

• Missing test results
• Invalid or missing signature requirements
• Missing order record or clinical documentation from the ordering or referring provider

“A DXA test must include the report with assessment as it relates to the medical history of the patient and interpretation. The report must be separate and distinct from an evaluation and management (E/M) visit,” Juarez says. Additionally, the report needs to show the T and Z scores according to Juarez. A T score evaluates the strength of the bone and the estimated risk of the patient experiencing a fracture, whereas a Z score compares the patient’s bone density with that of an average person of the same age and sex.

By reviewing the requested ADR documentation, your practice will know which missing documents to obtain and submit. Additionally, if the referring or ordering provider is outside of your facility, then you may want to send a form letter to the provider. The form letter allows you to alert the external provider that they need to submit any missing documentation before the 45-day period ends.

Error 3: Medical Necessity Isn’t Supported by Documentation

Consider a scenario where the radiologist or physician provided ample documentation with signatures and test results, but the documentation didn’t contain information regarding the patient’s condition that warranted a claim of 77080. Without the medical necessity in the documentation, the provider is unable to meet the conditions required for coverage.

“The scans are primarily for women 65 years and older. However, women 50 to 64 years old may be considered an exclusion if they have a combination of risk factors (as determined by age) or one or more of the ‘independent risk factors,’” Juarez says.

One of those independent risk factors includes a 10-year probability of a major osteoporotic fracture of 8.4 percent or higher as determined by a Fracture Risk Assessment Tool (FRAX). If your provider is treating a patient diagnosed with osteoporosis, then Medicare should see medical necessity supported by a DXA scan of the axial skeleton.