Check your LCDs to see if coverage is once every 2 years.
If you find tracking Medicare's DXA claim restrictions on medical necessity and frequency a real chore, you're not alone. But you can simplify the process and reduce denials by following this expert advice on keeping DXA claims airtight.
Scenario: Your physician orders an axial skeleton DXA for an estrogen-deficient female patient at risk for osteoporosis. You should report 77080 (Dual-energy X-ray absorptiometry [DXA], bone density study, 1 or more sites; axial skeleton [e.g., hips, pelvis, spine]) with V82.81 (Special screening for osteoporosis).
ICD-10: When your diagnosis coding system changes in 2014, V82.81 will become Z13.820 (Encounter for screening for osteoporosis).
For measuring bone density, dual-energy x-ray absorptiometry (DXA) is the gold standard.
Tip 1: Get Your Documentation in Order
Your documentation must include an order from a physician or qualified nonphysician practitioner and an interpretation of the test results (Medicare Benefit Policy Manual, Chapter 15, Section 80.5.4). Signing the machine printout doesn't count as an interpretation.
The physician also needs to document a complete diagnosis. Medicare doesn't offer a national list of covered ICD-9 codes, but it does state that an individual qualifies for coverage when she meets one of these conditions:
is estrogen-deficient and at risk for osteoporosis
is being monitored for FDA-approved osteoporosis drug efficacy has been diagnosed by x-ray with osteoporosis, osteopenia, or vertebral fracture
is receiving glucocorticoid therapy greater than or equal to 7.5 mg of prednisone per day for more than three months has primary hyperparathyroidismcacy.
Check your payer's local coverage determination (LCD) for the specific ICD-9 codes it says support medical necessity.
Example: Aetna lists several diagnoses that may prove medical necessity, such as 627.2, (Symptomatic menopausal or female climacteric states) and 733.90 (Disorder of bone and cartilage, unspecified).
ICD-10: When your diagnosis system changes in 2014, 627.2 will become N95.1 (Menopausal and female climacteric states). Code733.90 will become M89.9 and M94.9 (Disorder of bone and cartilage, unspecified)
Tip 2: Stick With Documented Diagnoses
Only report the documented diagnosis -- never choose a diagnosis simply because you know you'll get paid for it.
Don't forget: You should always code results to the highest level of specificity. For example, for a woman who is postmenopausal and not taking hormones, you should report V49.81 (Asymptomatic postmenopausal status [age-related] [natural]).
ICD-10: When your diagnosis system changes in 2014, V49.81 will become Z78.0 (Asymptomatic menopausal state).
Tip 3: Adhere to Frequency Guidelines
Medicare will pay for bone mass measurements on qualified individuals every two years.
Translation: Every two years means "at least 23 months have passed since the month" of the last bone mass measurement (Medicare Benefit Policy Manual, Chapter 15, Section 80.5.5). Medicare does offer exceptions to this frequency rule. Payers may consider more frequent DXA scans when medically necessary under either of these circumstances, she adds:
you're monitoring a patient on glucocorticoid therapy for more than three months
you need a baseline measurement to monitor a patient who had an initial test using a different technique (such as sonometry) than the one you want to use to monitor the patient (such as densitometry).
G0130-Single energy x-ray absorptiometry (sexa) bone density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel) is a non-invasive technique to measure bone density to predict fracture risk mainly in osteoporosis. The test involves passing of x-ray beams from single source through the peripheral bones. The bone with high density will not allow passage of x-rays through and low density one will allow the same. This procedure is a preventive service covered by Medicare. The service is mainly entitled for the women who are estrogen deficient and at risk of osteoporosis, individuals with vertebral abnormalities, patients receiving steroid therapy or with primary hyperparathyroidism. Medicare provides coverage for bone density study to the beneficiaries once in every two years generally and more frequently if it is medically necessary. Other situations can be, if the patient is on long term steroid therapy for more than three months.