Ob-gyn coders have notoriously struggled to get Medicare reimbursement for dual energy x-ray absorptiometry (DEXA) scans. CMS not only restricts medical necessity and frequency of the exams but also limits the diagnoses that justify the scans. First, Know the Codes Physicians use DEXA scans to test for osteoporosis (733.00). Consequently, many female Medicare patients receive this test. The scans allow ob-gyns to track a patient's bone loss as well as monitor the positive effects of any treatments, such as estrogen replacement therapy, on the condition.
CPT provides three codes for DEXA scans:
76075 Dual energy x-ray absorptiometry (DEXA), bone density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)
76076 appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
0028T Dual energy x-ray absorptiometry (DEXA) body composition study, one or more sites. "My routine is to order the DEXA scan done at a facility, which then sends me the raw data," says Harry L. Stuber, MD, an independent gynecologist based in Cookeville, Tenn. He then reviews the data and prepares a report, billing 76075-26 (Professional component). The facility that performs the test reports 76075-TC (Technical component).
"I then have the patient back for a 10- or 15- (occasionally 25) minute face-to-face encounter in which I explain where she stands, how she compares to the 'ideal' 30-year-old woman (T score) and also to other women her own age (Z score)," Stuber says. For this visit, he bills 99212-99214 (Office or other outpatient visit for the evaluation and management of an established patient ).
But justifying bone density studies has been difficult because carriers have created lists of covered diagnoses that do not always correspond with the reason the patient is suspected of developing osteoporosis. The key to remember, however, is that DEXA scans are frequently a diagnostic test rather than a screening test. The physician must have documented that, based on symptoms or medical history, the patient is at high risk for developing osteoporosis. Medical Necessity Remains the Key According to section 4181.1 of the Medicare Carriers Manual (MCM), Medicare will pay for a bone mass measurement if the physician performs it on a "qualified individual." A qualified individual is a Medicare beneficiary who falls into at least one of the following medical categories:
a woman whose healthcare provider has determined that she is estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings
an individual receiving (or expecting to receive) glucocorticoid therapy [...]