Radiology Coding Alert

A little digging into your local policy can prevent denials.

DXA is the gold standard for bone screenings -- a common test for the aging population. Medicare has set up a mix of national and regional rules you need to keep tabs on for claim success. Get started by making sure you have these three areas covered.

The codes: There are several bone mass measurement codes, but here the focus will be the following:

1. Factor in Frequency Guidelines

Medicare's general rule is that carriers pay for a screening bone mass measurement (BMM), including 77080 and 77081, "once every 2 years (at least 23 months have passed since the month the last covered BMM was performed)" (Medicare Benefit Policy Manual, [MBPM], chapter 15, section 80.5.5).

In some cases, you may not know when the patient last had a DXA scan. If you cannot locate the date of the previous scan (although a call to the payer may help clear the question), you'll want to ask the patient to sign an advance beneficiary notice (ABN), says Barbara J. Cobuzzi, MBA, CPC, CPCH,CPC-P, CENTC, CHCC, with CRN Healthcare Solutions in Tinton Falls, NJ.

Exception: "If you can document medical necessity on the patient, Medicare will allow you to bill within the two-year window," advises Martha A. Conradson, administrator for Desert Bloom Family Medicine in Phoenix. "Otherwise, the two-year rule for all 'healthy' individuals is a good guideline to follow."

Two examples of when earlier tests might be necessary include:

Smart move: Read all of MBPM, section 80.5, for additional information on conditions for coverage.

2. Identify Which ICD-9 Codes Make the Grade

Medicare Claims Processing Manual (MCPM), chapter 13, section 140, offers you a helpful start on which diagnosis codes prove medical necessity for 77080 and 77081. But note that for 77081, you'll need to check your local contractor's policy to get the full picture.

77080: Codes 733.0x series (Osteoporosis), 733.90 (Disorder of bone and cartilage, unspecified), or 255.0 (Cushing's syndrome) each earn coverage for 77080.

77081: Medicare covers 77081 claims with the above ICD-9 codes only if you also report a valid ICD-9 code from the list your local contractor maintains to indicate the reason a physician ordered the screening -- postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.

Remember: Proper coding requires you to report diagnosis codes supported by the documentation. You should never report a code simply because it will get a claim paid.

3. Don't Confuse 77080, 77081 Coverage With 77082

In recent Transmittal 700, Change Request 6973 (www.cms.gov/transmittals/downloads/R700OTN.pdf), Medicare announced a relative value unit (RVU) increase for 77080 and 77082 (... vertebral fracture assessment). But you can't assume that the RVU increase equates to automatic coverage for 77082.

Some payers consider the service investigational and will not reimburse the code. Others may have specific medical necessity requirements. For example, National Government Services and Palmetto's local coverage determinations (LCDs) for BMM state that 77082 is not a bone density study so you should not bill it for a screening. "This code may be billed when medically necessary (i.e. when a vertebral fracture assessment is required). Symptoms should be present and documented, and it should be anticipated that the results of the test will be used in the management of the patient."

Resources: Search coverage policies online at www.cms.gov/mcd/search.asp. And download Medicare manuals at www.cms.gov/Manuals/.