Radiology Question for the Week of June 6, 2016

Question:

Question:

We have many referring physicians ordering bone density exams (77080) with the diagnosis of Z13.820 (encounter for screening of osteoporosis).  The claims for these are being denied by Medicare with the message “non-covered routine exam.”  Doesn’t Medicare pay for a screening bone density scan every two years?   

Answer:

Answer:

Medicare does not cover or reimburse a true screening bone density exam.  Medicare covers bone density exams only when the patient has documentation of one of the five qualifying circumstances listed below:

(1)  A woman who has been determined by the physician (or a qualified nonphysician practitioner) treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings 
(2) An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture
(3)  An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg of prednisone, or greater, per day for more than 3 months
(4) An individual with primary hyperparathyroidism
(5) An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy

The diagnosis code you report must indicate one of the above qualifications. Medicare will always deny Z13.820 if it is the primary or only diagnosis code.  

The Medicare national coverage determination (NCD) can be found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1580OTN.pdf. Additional diagnoses for osteopenia that were left out of the original NCD file can be found at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1525.pdf.