Wiki Osteopenia of Hip , Osteopenia of Spine

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BrendaC1957

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We perform DXA studies in our office. The DXA measures the bone density of the femoral neck and the spine. I have been looking for the specific ICD-10 for osteopenia of the femoral neck and/or the spine. All I can find in the M85.8 section is thigh , left or right, which is not a hip. For the spine, I don't find anything close to the spine. I see the M85.88, Other Site or the M85.89, Multiple sites. Are these the correct codes for osteopenia of the femoral neck, the spine, or femoral and spine? Any suggestions?
 
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mccoyheather said:
Yes, but the overall "osteopenic" DEXA T-score should give a specific number and possibly M81.0 would apply based on the score. If the patient has a known fracture the fracture codes may apply see M80 codes, for example M80.08XA and code second the vertbrae site of fracture. Check you dexa report for the T-score level:
A T-score of +1 to -1: normal bone mineral density. A T-score of -1 to -2.5: osteopenia. A T-score of -2.5 or lower: osteoporosis. Severe Osteoporosis is diagnosed when the T-score is -2.5 or lower, and the person has already suffered a fragility fracture.
Note: the purpose of the Dexa score is to categorize the "risk" for osteo.... dx + fracture risk.
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I understand what you are saying, but at the same time I feel that based on your response, we must give all patients a diagnosis of osteoporosis "M81.0" without a physicians interpretation.

Keep in mind that we as coders cannot assume or interpret labs/imaging results. Yes, if the indication for the procedure is the diagnosis of osteoporosis then yes it's good for the coder to code it as such, but if they are only providing the diagnosis of osteopenia, then that's what is documented. If the coder feels there is a diagnosis of osteoporosis based on the results, then the best approach will be to query the provider for a more specific diagnosis, if applicable.

But other than that, if the diagnosis is osteopenia and there is no mentioning of osteoporosis, it wouldn't be safe to code osteoporosis based on scores, unless we have a specific guideline that allows us to. That's my opinion.
 
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The best code one can come up with for osteopenia of the spine or the femoral neck would be M85.88 for other site. Now if you are dealing with different sites, you also have M85.89 for "multiple sites"

hope this helps.
 
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Yes, but the overall "osteopenic" DEXA T-score should give a specific number and possibly M81.0 would apply based on the score. If the patient has a known fracture the fracture codes may apply see M80 codes, for example M80.08XA and code second the vertbrae site of fracture. Check you dexa report for the T-score level:
A T-score of +1 to -1: normal bone mineral density. A T-score of -1 to -2.5: osteopenia. A T-score of -2.5 or lower: osteoporosis. Severe Osteoporosis is diagnosed when the T-score is -2.5 or lower, and the person has already suffered a fragility fracture.
Note: the purpose of the Dexa score is to categorize the "risk" for osteo.... dx + fracture risk.
 
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