Radiology Coding Alert

Follow the two-year rule and limit diagnosis coding to screening encounters.

If you don’t have your codes arranged perfectly when your radiologist performs bone density screening, then your claim could crumble into a denial disaster. Here is how you can build a clean claim for bone density screening. Also important is to understand when the physician can advise a screening. Not all conditions qualify.

Who Qualifies for Bone Density Screening?

Before you submit claim for bone density screening, confirm if the patient qualifies for the procedure. “Women of postmenopausal age, women who may be estrogen deficient and at risk for osteoporosis, men or women receiving a steroid or osteoporosis therapy, and patients with hyperparathyroidism should be screened for bone density,” says Dianne Nakvosas, ACS-RAD, Compubill, Inc., IL.

According to section 80.5.6 of chapter 15 of the Medicare Benefit Policy Manual, a patient must meet at least one of five indications to qualify for a bone density screening:

• Any woman who has reduced levels of estrogen, which is considered an ovarian failure (E28.39, Other primary ovarian failure) and at clinical risk for osteoporosis
• Any person with abnormalities of the vertebra suggestive of osteoporosis, osteopenia, or vertebral fracture
• Any person who is on medications such as glucocorticoids equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than three months (Z79.52, Long term [current] use of systemic steroids)
• Any person with primary hyperparathyroidism (E21.0, Primary hyperparathyroidism)
• A patient who needs monitoring because of Food and Drug Administration-approved osteoporosis drug therapy (such as Z79.52).

First, Get the Frequency Right

When reporting screening services with bone density assessments, you will first need to make sure that the patient qualified for the screening. Check how often your physician is doing the screening. According to Medicare the usual time gap between screenings in two years.

Follow the two-year rule: Medicare will pay for bone mass measurements for patients who meet the required criteria for screening once every two years.

What does every two years mean? According to section 80.5.5 of chapter 15 of the Medicare Benefit Policy Manual, “every two years” means “at least 23 months have passed since the month” of the last Medicare covered bone mass measurement.

Early screenings are exceptions: In some cases, Medicare will permit your physician to screen a patient even though two years have not passed since the last screening. You will need to prove the medical necessity. “Medicare will cover bone densities earlier than 2 years but after 11 months from their previous measurement if the patient is on long-term glucocorticoid therapy of more than 3 months or if taking a FDA approved osteoporosis drug therapy,” says Nakvosas.

Here are examples of situations in which you can claim an early screening:

1. If your physician is treating a patient who is on glucocorticoid therapy for a span of more than three months, then a regular and more frequent screening of bone density is therefore the norm. Glucocorticoid therapy is a risk factor for osteopenia. You can submit screening claims even if at least 23 months have not elapsed since the last screening for that patient.
2. Your physician may switch the screening modality to assess the bone density. This entitles you to submit the claim for the second screening even if at least 23 months have not elapsed since the last screening. For example, in a patient who was earlier detected borderline bone density in an ultrasound assessment, your physician may want to repeat the bone density measurement with a densitometry.

Tip: Don’t forget the documentation you will need to submit an earlier screening. Make sure your physician has adequately described the medical necessity for the early screening.

Don’t forget the ABN: You should get the patient to sign an Advanced Beneficiary Notice (ABN) before you undertake the screening when you are not able to verify the date of the last screening. This may apply in the following situations:

• There is no documentation of when the patient last received a bone density scan
• The patient has no recollection of when the last bone density screening was done.

Confirm Modality to Get To the Right Code

Check how your physician assessed the bone density. There are more than one modalities available for bone density assessments. “Dual-Energy X-Ray Absorptiometry (DXA) is a common modality for bone density study,” says Nakvosas.

When your clinician does DXA, you choose from the following CPT^® codes depending on the anatomical area which your clinician assessed:

• 77080, Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)
• 77081, ...appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
• 77085, ...axial skeleton (e.g., hips, pelvis, spine), including vertebral fracture assessment
• 77086, Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA).

Example: Bone density assessments are commonly done in the distal forearm (wrist). You may read that the physician did an appendicular skeleton (wrist) DXA in a menopausal 48-year-old female patient who was suspected to be at high risk of osteopenia.

In this case, you submit code 77081, assuming your practice provided both the technical and professional components of the service. If your clinician only provided the interpretation for the test, you will need to report only the professional component of the service. For this, you will need to append the modifier 26 (Professional component) to 77081.

There are however other modalities that Medicare recognises for bone density assessments. Check from the following codes for these assessments:

• 76977, Ultrasound bone density measurement and interpretation, peripheral site(s), any method
• 77078, Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)
• G0130, Single energy X-ray absorptiometry (SEXA) bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel).

Always Include the Diagnosis Codes

When submitting claims for screening for bone density, you need to be careful in making a choice for the diagnosis codes. Remember, you are submitting a claim for screening and not for the diagnosis of osteoporosis or osteopenia.

Be specific for the screening encounter: When your physician is screening for the suspected bone condition, i.e. osteoporosis or osteopenia, you will submit code Z13.820 (Encounter for screening for osteoporosis) to support the medical necessity of the screening. If the encounter is just a screening and nothing (osteoporosis/osteopenia) shows, then you must use the screening ICD-10 code of Z13.820, but this code by itself does not support medical necessity, therefore you may want to have a ABN (Advance Beneficiary Notice of Noncoverage) signed by the patient before doing the procedure,” Nakvosas says.

You can also report additional diagnosis codes that support the necessity of conducting the screening. For example, if your clinician is performing the screening on a woman who has reached menopause but has no other symptoms, you will report Z78.0 (Asymptomatic menopausal state) along with Z13.820.

Say no to M codes: You cannot use M codes specific for osteoporosis or osteopenia, i.e.

• M81.0, Age-related osteoporosis without current pathological fracture
• M85.8-, Other specified disorders of bone density and structure

These M codes apply when the patient has already been diagnosed with either of the bone conditions and not when they are being screened.

Read more: For more information, check this link at https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS-QuickReferenceChart-1TextOnly.pdf.