Wiki DEXA with osteoporosis

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kimberagame

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We have a patient needing a DEXA to monitor her osteoporosis, which she is currently taking Prolia for. I would expect to bill this with a dx code for osteoporosis - M81.0, but she is insisting that we use the screening code, Z13.820. Her insurance has told her that this is the correct code for her situation - having osteoporosis and needing a DEXA to monitor treatment. They told her it remains a screening test until she has an actual fracture. The rep even went and consulted with their supervisor and called the patient back to confirm this was correct. This is completely wrong according to everything I've ever learned about when to use screening codes. Has anyone else heard of this? If the payer can send us documentation confirming this is how they handle that situation, are we safe to bill it that way, despite it not matching ICD guidelines?
 
I work for an insurance company, and we would never advise a member to do what your patient has been advised to do here and I don't blame you for being wary of doing this. As we all know insurance companies often want things billed a specific way for benefits to be applied regardless of the coding guidelines. I would say if you can get in writing that this is their policy you can try and do what the member wants; however, I have a hard time believing you are going to get them to put it in writing. Good luck to you and your patient.
 
This doesn't make a lot of sense to me. Patients and insurance companies say a lot of things that aren't correct.
I agree with you it totally goes against the ICD-10 guidelines Chapter 21 c. 5) Screening.

How could it be screening since it's already been a confirmed diagnosis of osteoporosis and she is undergoing treatment? You're not screening for it anymore once she has been diagnosed/under treatment.

I would not do this. We can't bill and code just because "Her insurance has told her that this is the correct code for her situation"
I empathize with your plight, this happened to me all the time when handling DXA billing/coding and trying to explain to patients and providers why we can't just slap on the Z code to everything.
I am curious who the payer is but I understand you not being able to post it.
 
Thank you all for your replies. The patient wants to get us contact info for the people she spoke with. If they can provide us with documentation to support what they're saying, my superiors and I will have to make a decision about whether to follow it or not. If they don't get that to us, we'll definitely not be billing it as screening.
 
kimberagame said:
Thank you all for your replies. The patient wants to get us contact info for the people she spoke with. If they can provide us with documentation to support what they're saying, my superiors and I will have to make a decision about whether to follow it or not. If they don't get that to us, we'll definitely not be billing it as screening.
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Depending on the payer, you should be able to find a DXA policy in their policy manual or coverage guidelines. Most payers have a policy on this because it's always an issue. If it's a small or rare plan probably not. Agree, don't do it "wrong" unless they can give you a written, current and in-force guideline/policy on it.

I pulled this from LCDs but would also make sure everyone is talking about the same CPT code/procedure(s). When you mentioned above they started talking screening vs. fracture it made me think of this. 77078 vs. 77082, etc.

"9. CPT code 77082 is considered by Medicare to represent vertebral fracture assessment only. Because
code 77082 does not represent a bone density study, it should NOT be billed for 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."
 

Hi kimberagame,​

This seems unusual coding but this may be a "payer" specific requirement. Please don't brush it off ~ these policies unfortunately really do exist. Bill it like they expect you to. If you are denied. You have all the paperwork scanned in the referral source or media tab to prove that this is how they (insurance) wanted this billed out. Be the glitter (to provide the documentation) on this scenario to achieve reimbursement.
Thank you for listening,
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB, RHIT
 
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