Radiology Coding Alert

Question: Our Medicare contractor has been denying 77080 as not paid as separate procedure and not a medical necessity when billed with 77081, even if the patients last DXA was more than 24 months ago. The diagnosis codes we use are 733.01, 733.02, 733.09, and V49.81. Should we use a modifier on the claim to stopgetting these denials?

Illinois Subscriber

Answer: CMS has a mutually exclusive edit that places 77081 (Dual-energy X-ray absorptiometry [DXA],bone density study, 1 or more sites; appendicular skeleton [peripheral] [e.g., radius, wrist, heel]) in column 1 and 77080 (& axial skeleton [e.g., hips, pelvis, spine]) in column 2. This edit has a modifier indicator of 1.

Chapter 9 of the National Correct Coding Initiative Policy Manual states, Although it may be medically reasonable and necessary to report both axial and peripheral bone density studies on the same date of service, NCCI edits prevent the reporting of multiple CPT codes for the axial bone density study or multiple CPT codes for the peripheral site bone density study on the same date of service.

Experts indicate this means that you should be able to append modifier 59 (Distinct procedural service) to override the edit when you meet the reasonable and necessary criteria.

Snag: You will need to check your payers policy on when it considers 77080 and 77081 performed on the same date to be reasonable and necessary.

For example, WPS Medicare states, Medicare will not reimburse for both axial and appendicular testing on the same date of service or within 30 days of each other,unless the medical records substantiate that the BMM initially obtained was unreadable. Conditions that verify to Medicare that a BMM is unreadable and a second BMM is medically necessary include documentation the patient has artificial instrumentation in place in either hip or spine, or other conditions that preclude a reading in those locations(www.wpsmedicare.com/part_b/policy/ms004.pdf).

And TrailBlazer allows payment for both axial and peripheral studies on the same day only when the peripheral study is performed first and the axial study has to be performed for confirmatory purposes. (Find this TrailBlazer LCD at www.trailblazerhealth.com. Click onLocal Coverage Determinations, and search for 77080.)

If you meet the requirements for medical necessity for the second study, report 77081 and append modifier 59 to 77080. And if youre in an office or imaging center, be sure you have orders for both exams from the treating physician.

77080: Codes 733.0x series (Osteoporosis), 733.90 (Disorder of bone and cartilage unspecified) or 255.0 (Cushings 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 (CMS transmittal 1416,www.cms.hhs.gov/transmittals/downloads/R1416CP.pdf).