Radi BoneDensity slide11 - AAPC

Documentation Dissection

Result Type: Bone Density Interpretation |1|.

Result Status: Final.

Bone Mineral Density Report Davison of Endocrinology and Metabolism

LIMITATIONS OF STUDY: Scoliosis noted. Lumbar spine densitometry readings on a patient with these skeletal abnormalities are suspect for giving falsely elevated values. Therefore, a forearm scan was completed to provide more information |2|.

HISTORY: 71-year-old Caucasian female. The patient weighs 130 pounds and is 60.5 inches tall. The body mass index is 24.97. Menopause began at approximately 57 years of age |3|. The following medical problems impact on this patient's bone health: Thyroid Disease (hypothyroidism). Patient does not smoke or consume more than 3 alcoholic beverages per day |4|. There is no history of hip fractures in her parents |5|. Pertinent medication history includes: Steroids (injection in spine). Thyroid Hormone (still taking) |6|. Hormone Replacement Therapy (still taking). Supplemental Calcium (1200 mg calcium with vitamin D daily and multivitamin).

FINDINGS: Lumbar Spine AP view (L1, L2, L3, and L4.) BMD = 0.917 g/cm2, T-Score * = -1.2, Z-Score ** = 1 |7|.

Left Hip - Total Hip

BMD = 0.819 g/cm2, T-Score * = 1.01, Z-Score ** = 0.58 |7|.

Neck

BMD = 0.66 g/cm2, T-Score * = -1.71, Z-Score ** = 0.17 |7|.

Trochanter

BMD = 0.562 g/cm2, T-Score * = -1.4, Z-Score ** = -0.01 |7|.

Forearm

BMD = 0.545 g/cm2, T-Score * = -0.37, Z-Score ** = 1.9 |7|.

ASSESSMENT: 1. Osteopenia |8|.

2. Since the DXA study dated 01/14/20XX, there has been a statistically significant increase in bone density in the lumbar spine on AP view (+1.9 % per year) and a statistically significant decrease in the total hip density (-2.2 % per year).

3. Since the DXA study dated 09/04/20XX, there has been a statistically significant increase in bone density in the lumbar spine on AP view (+1.0 % per year) and a statistically significant decrease in the total hip density (-1.0 % per year).

4. In this series of DXAs, the hip measurements, rather than spine measurements (scoliosis), are more likely to accurately reflect true change in bone mineral density.

COMMENTS:

1. The National Osteoporosis Foundation recommends initiation of therapy in postmenopausal women and in men age 50 and older with low bone mass T score -1 to -2.5 at the femoral neck, total hip, or spine and 10 year hip fracture risk equal or greater than 3% or a 10 year all major osteoporosis-related fracture risk probability of 20% or more based on the US-adapted WHO absolute fracture risk model (February, 20XX). In this patient a 10 year hip fracture risk is 1.9 % and a 10 year all major osteoporosis - related fracture risk probability is 11 %. (if there is no history of previous fracture in adult life occurring spontaneously, or a fracture arising from trauma which, in a healthy individual, would not have resulted in a fracture; no history of parent fractured hip, current smoking, glucocorticoid use for longer than 3 months at a dose equivalent to prednisolone 5 mg daily or more, confirmed diagnosis of rheumatoid arthritis, secondary osteoporosis, alcohol consumption of 3 or more units per day). By these recommendations no treatment is required. If the above mentioned fracture risk factors are present a fracture risk in this patient may be higher and treatment may be indicated. A fracture risk calculation tool FRAX was used to calculate the fracture risk in this patient: .

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2. General Measures: Patient's daily calcium intake should equal 1200 to 1500 mg. Dietary intake averages 600 mg/day. Supplemental calcium should be taken to make up the difference. Vitamin D intake should be 800 IU/day. Reasonable weight bearing exercise should also be encouraged.

3. Follow-up bone density measurement should be considered in greater than 24 months to assess need for therapy.

4. Clinical correlation is required, because no specific bone disease can be diagnosed or excluded on the basis of these findings.

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|1| Indication of imaging performed.

|2| Documentation supporting the additional studies of the forearm performed.

|3| Patient is menopausal which is important in determining the diagnosis code.

|4| Problems that could raise risk of osteoporosis (in this patient hypothyroidism).

|5| Past fractures or family history could alter the ICD-10 code selection.

|6| Medications that could put the patient at increased risk of osteoporosis.

|7| Indicates the axial skeleton was imaged (spine and hips) for code 77080-59 and the forearm for code 77081.

|8| Diagnostic finding.

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What are the CPT? and ICD-10-CM codes reported?

CPT? Codes: 77080-59, 77081

ICD-10-CM Codes: M85.80, E03.9, M41.9, Z79.890

Rationales: CPT?: Look in the CPT? Index for Bone Density Study/Axial Skeleton referring you to 77078, 77080. Further clarification in the code set verifies 77080 is appropriate to report for an axial bone density study. 77078 reports a CT bone mineral density study which was not performed. There is an additional study performed on the forearm due to scoliosis, which can give false positive results. Look in the CPT? Index for Bone Density Study/Appendicular Skeleton referring you to 77081. The note does not indicate that only the interpretation or imaging was performed so we will not append the professional/technical modifiers, but instead bill this as a global procedure. Verify code selection in the Numeric Section. Modifier 59 is appended to 77080, because it is usually bundled with 77081. In this case it is separate, due to the need for further study.

ICD-10-CM: In the ICD-10-CM Alphabetic Index look for Osteopenia which directs you to M85.8-. The specific location of Osteopenia is not indicated in the documentation so we will have to use the unspecified code, M85.80. Verify code selection in the Tabular List.

Look in the ICD-10-CM Alphabetic Index for Hypothyroidism which directs you to E03.9. Without additional information regarding the hypothyroidism, we must use the unspecified code, E03.9. Verify code selection in the Tabular List.

In the ICD-10-CM Alphabetic Index, look for Long-term/Hormone replacement (postmenopausal) which directs you to code Z79.890. You can also look for Therapy/drug, long-term (current) (prophylactic)/hormone replacement (postmenopausal). Verify code selection in the Tabular List. Scoliosis is reported because it is the reason for the forearm scan, because lumbar spine densitometry readings for a patient with scoliosis may give falsely elevated values. Look in the Alphabetic Index for Scoliosis. Verify in the Tabular List. M41.9 must be linked with 77080 on the claim form. The main reason for the tests was for the osteopenia.

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