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Documentation needed for DEXA

Kristene Posted Wed 29th of May, 2013 15:10:01 PM

Can anyone tell me what documentation requirements are needed to bill for a bone density interpretation and report? Specifically wondering if a letter to the patient regarding the DEXA results is appropriate enough documentation to count as interpretation or if a separate note on the interpretation is needed?

SuperCoder Answered Thu 30th of May, 2013 00:19:06 AM

Medicare LCDs for DXA tend to focus on documentation including orders and medical necessity rather than describing the format of the interpretation.

You want to have an official interpretation as part of the written report that stays in the patient’s medical record. If the letter meets the same content standards that apply to a stand-alone interpretation, you should be OK. Review the ACR documentation recommendations starting on page 5: http://www.acr.org/~/media/EB34DA2F786D4F8E96A70B75EE035992.pdf.

Also look at the report info on page 2 here: http://www.acr.org/~/media/C5D1443C9EA4424AA12477D1AD1D927D.pdf

NGS Medicare points to ACR guidelines for interpretation and report on slide 38 here: http://www.ngsmedicareconvention.com/wps/wcm/connect/1d0627004ad29c91a979abf3da0c6d75/1206_0312B1.6_Diagnostic_Radiology_Billing.pdf?MOD=AJPERES

Medi-Cal offers similar advice, referencing a range that includes DXA codes:

Treating physicians may be reimbursed for the professional component of an X-ray procedure performed on a recipient in an outpatient setting (including an emergency room), in addition to being reimbursed for Evaluation and Management (E&M) CPT-4 codes 99201 – 99499 (except 99211), when a separate report is produced that includes an interpretation and written report for the recipient’s medical record. The X-ray interpretation should be a separately written report and not simply contained within the E&M report.

Note: Treating physicians (such as but not limited to emergency room physicians, orthopedic surgeons, trauma specialists, surgeons, internists, family physicians and podiatrists) who routinely review radiographs as an integral part of their reimbursed E&M services are usually not entitled to reimbursement for the professional component of the radiographic review. This service, like other diagnostic data evaluations, is usually covered by the reimbursement for the E&M.

The separately written interpretation is reimbursable only for CPT-4 codes 70010 – 77084 and must include the following:
• Recipient’s name and hospital identification number (if applicable)
• Name or type of examination
• Date of examination
• Interpretation that includes a complete exam of the X-ray using precise anatomic and radiologic terminology
• Pertinent clinical issues and an “impression” section
• Signature of the physician supplying the interpretation

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