Radiology Coding Alert

Question: Should I write off a Medicare frequency denial for a dual-energy X-ray absorptiometry (DEXA) scan that the radiologist performed to monitor a previously diagnosed osteoporotic patient? The last scan was 12 months ago.

Texas Subscriber

Answer: The National Coverage Determination (NCD) 150.3 for Bone (Mineral) Density Studies will refer you to Chapter 15, Section 80.5 of the Medicare Benefit Policy Manual (MBPM) for further guidance on claims processing for bone density studies, such as DEXA scans. In the MBPM, the Centers for Medicare & Medicaid Services (CMS) outlines their policy on reimbursement for screening for bone mass measurements (BMMs) as the following:

“Medicare pays for a screening BMM once every 2 years (at least 23 months have passed since the month the last covered BMM was performed).”

This policy doesn’t tell the entire story, though. Getting reimbursed for code 77080 (Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)) twice in a two-year period is possible, but you’ll have to appeal the denial on the basis that the follow-up scan is for monitoring purposes. As you’ll see in the policy guideline, CMS restricts payment for “screening” BMMs to one every two years, but they don’t necessarily rule outpatients with a preexisting osteoporosis diagnosis.

CMS elaborates further in the next part of the policy by addressing the following instances in which BMMs performed on a more frequent basis than two years will be reimbursed:

• “Monitoring beneficiaries on long-term glucocorticoid (steroid) therapy of more than 3 months.
• “Confirming baseline BMMs to permit monitoring of beneficiaries in the future.”

While neither of these examples perfectly align with the clinical scenario presented above, CMS does explain that payment for higher-frequency BMMs are not exclusive to those two examples. While there are no guarantees of reimbursement, you should submit an appeal using this portion of the MBPM as justification. Furthermore, you should include all relevant diagnostic information that supports the fact that the radiologist performed the follow-up DEXA scan for monitoring purposes.