Decoding DEXA Scan Diagnosis Codes: Ensuring Medicare Coverage

Navigating the complexities of medical billing, especially for procedures like DEXA scans (Dual-Energy X-ray Absorptiometry), requires a thorough understanding of Medicare guidelines and covered diagnosis codes. For healthcare providers aiming to secure proper reimbursement for bone mass measurement services, accurate coding and documentation are paramount. This guide breaks down the essential aspects of Medicare coverage for DEXA scans, focusing on diagnosis coding, Advance Beneficiary Notices (ABNs), and crucial documentation requirements to ensure compliance and avoid claim denials.

Understanding Medicare Coverage for DEXA Scans

Medicare Part A and Part B have specific guidelines governing the coverage of bone mass measurements, including DEXA scans. It’s critical to understand that Medicare reimbursement hinges on medical necessity and appropriate diagnosis coding. Submitting claims with valid ICD-10-CM codes that accurately reflect the patient’s condition and the reason for the DEXA scan is the first step towards ensuring coverage. Claims lacking a proper diagnosis code will be deemed incomplete and returned. For diagnostic tests like DEXA scans, the diagnosis code should ideally represent the confirmed diagnosis. However, if the diagnosis is not yet confirmed, the presenting symptoms that prompted the scan should be clearly documented and coded.

Navigating Advance Beneficiary Notices (ABNs) for DEXA Scans

In scenarios where a DEXA scan might not be covered by Medicare, issuing an Advance Beneficiary Notice of Non-coverage (ABN) becomes crucial. An ABN informs the patient that Medicare may not cover the service and that they may be financially responsible. Using the correct modifier with your claim based on the ABN situation is essential for proper processing.

ABN Modifier Guidelines for DEXA Scans:

• -GA Modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”): Use this modifier when you anticipate Medicare denying the DEXA scan as not reasonable and necessary, and you have a signed ABN from the patient. This signifies that the patient is aware of potential non-coverage and accepts financial responsibility. For Part A MAC claims, Modifier GA will result in automatic denial, and occurrence code 32 along with the ABN date is required. This modifier is applicable when denials are expected under sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act related to reasonable and necessary provisions.
• -GX Modifier (“Notice of Liability Issued, Voluntary Under Payer Policy”): Employ Modifier GX when an ABN is signed, and denial is expected for reasons other than medical necessity, such as statutory exclusions or technical issues. While an ABN isn’t mandatory for these situations, using Modifier GX will lead to automatic claim denial.
• -GY Modifier: Use Modifier -GY when the service is statutorily non-covered or lacks a Medicare benefit category. An ABN is not needed, and services with Modifier GY will be automatically denied.
• -GZ Modifier: Apply Modifier -GZ when you expect Medicare to deny the DEXA scan as not reasonable and necessary, and you do not have a signed ABN from the patient.

Essential Documentation for DEXA Scan Claims

Comprehensive documentation is the backbone of a successful Medicare claim for DEXA scans. Your patient’s medical record must clearly demonstrate the medical necessity for the test. Key documentation elements include:

• Ordering Provider’s Assessment: A detailed assessment by the physician or qualified non-physician practitioner justifying the need for the DEXA scan based on the patient’s presenting complaint during the visit.
• Relevant Medical History: Documentation of the patient’s medical history that is pertinent to their risk of osteoporosis or bone density concerns.
• Results of Pertinent Tests/Procedures: Include results of any prior relevant tests or procedures that support the need for a DEXA scan.
• Signed and Dated Records: Ensure all office visit records and operative reports are signed and dated by the rendering provider. Medicare mandates signatures on all services ordered or rendered to beneficiaries.

Limitations on DEXA Scan Coverage by Medicare

Medicare imposes certain limitations on the frequency and circumstances under which DEXA scans are covered. Being aware of these limitations is crucial for avoiding claim denials:

1. Physician/Qualified Practitioner Order: DEXA scans must be ordered by the physician or qualified non-physician practitioner who is actively treating the beneficiary. Tests ordered by other providers may not be considered reasonable and necessary.
2. Initial Bone Mass Measurement Frequency: Medicare typically reimburses for an initial bone mass measurement only once. Regardless of the number of sites scanned (e.g., spine and hip), CPT code 77080 should only be billed once for an initial measurement.
3. Multiple BMM Tests: Performing more than one type of bone mass measurement (BMM) test on the same individual is generally not considered medically necessary, unless a DXA confirmatory test is needed as a baseline for future monitoring.
4. Peripheral and Axial BMM Tests: Performing both peripheral and axial BMM tests on the same day is usually not reimbursable by Medicare.
5. Repeat DEXA Scans by Different Providers: Medicare may deny reimbursement for DEXA scans performed by a second provider if a test has already been conducted within the defined coverage period, unless it’s for confirmatory testing and future monitoring. Providers should attempt to obtain prior test results, and document any unsuccessful attempts to justify a new test.
6. Non-Covered Technologies: Older technologies like single and dual photon absorptiometry (CPT codes 78350 and 78351) are not covered by Medicare.
7. Portable X-ray Benefit Exclusion: Bone mass measurements are not covered under the portable x-ray benefit and will be denied if performed by a portable x-ray supplier. Transportation charges for BMM testing are also not covered.
8. Interpretation and Report Requirement: DEXA scan tests must include an accompanying interpretation and report to be considered medically necessary. The report must be separate from an evaluation and management note.
9. Vertebral Fracture Assessment (VFA) – CPT Code 77082: CPT code 77082 is specifically for vertebral fracture assessment and not considered a bone density study for screening purposes. It should only be billed when medically necessary due to symptoms, and when the results are expected to influence patient management.

Key Takeaways for DEXA Scan Diagnosis Coding and Coverage

Accurate diagnosis coding is fundamental for securing Medicare reimbursement for DEXA scans. While this guide provides comprehensive information on coverage guidelines, it is crucial to stay updated with the latest Medicare policies and Local Coverage Determinations (LCDs). Ensure your documentation clearly supports the medical necessity of each DEXA scan, utilize ABNs and appropriate modifiers when necessary, and be mindful of the limitations on coverage to optimize your billing practices and provide the best possible care for your patients. By adhering to these guidelines, healthcare providers can confidently navigate the billing landscape for DEXA scans and ensure appropriate reimbursement for these vital diagnostic services.