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When it comes to DEXA scans, you have to bill them with CPT codes 77080, 77081, and 77085, and also have to include modifiers and documentation to prove medical necessity. Knowing how to avoid claims being denied with the Medicare guidelines and the obvious frequency guidelines of the payers helps you get paid the fastest. If providers/facilities want to improve the efficiency of their billing, receive the fastest payments, and have the lower risk of audits, they need to do correct coding and billing, follow all the regulations, and do the compliance of verifying coverage.
A DEXA scan shows the bone mineral density diagnostic test called Dual-Energy X-ray Absorptiometry. DEXA scans are important when diagnosing osteoporosis, assessing the risks of fractures, and tracking the progress of osteoporosis treatment. DEXA scan test billing is crucial for healthcare providers as it secures reimbursement while adhering to guidelines that payers put in place. Mistakes in coding, modifier usage, and even documentation can end up causing health care providers to lose money on claims due to payments being delayed, or even risk going through an audit. Knowing the right CPT codes and using the right modifiers, and understanding reimbursement criteria, allows health care providers to control their revenues while being compliant to regulations.
.Understanding DEXA Scan
A DEXA scan is used to monitor bone health by tracking bone density in the forearm, hip, and spine and uses a small amount of X-ray radiation. Many patients on osteoporosis or osteopenia, and in treatment for the condition, do this test. The test is frequently requested for elderly patients, women who have ended the menopause and patients who are at greater risk of developing osteoporosis due to long-term steroid treatment or due to chronic diseases.
To bill for the DEXA scan, the patient’s record should reflect the medical necessity of the exam. Insurance companies want documentation reflecting appropriateness of the test given the patient’s risk factors, symptoms, or need monitoring ongoing treatment. Documentation warrants use of the CPT code and ensures reimbursement for the claim.
CPT Codes for Billing DEXA Scan
CPT Code 77080: DEXA Scan of the Axial Skeleton
CPT Code 77080 is a generic CPT code that denotes the DEXA scan of the axial skeleton, which is a bone density study of the hip and spine. This code encompasses the imaging, interpretation, and reporting, subsequent to the study. This code is utilized for the standard bone density test, which is done for the screening or monitoring of osteoporosis.
In order to use code 77080 accurately, there should be enough documentation reflecting the anatomical site assessed and also confirming that the DEXA test was done. Code 77080 is accepted by Medicare and other commercial payers as long as the medical necessity criteria is satisfied.
CPT Code 77081: Peripheral DEXA Scan
CPT Code 77081 indicates that the test is performed on peripheral site locations like the wrist, heel, or finger, or any other peripheral site. Peripheral scans are usually performed for screening purposes or if an axial test is unavailable. But, peripheral DEXA scans are not reimbursed as often as axial scans. Providers must make sure the documentation clearly states which peripheral site was tested and the justification for the peripheral DEXA as opposed to the axial DEXA, if relevant.
CPT Code 77085: Combined Axial and Vertebral Fracture Assessment
CPT Code 77085 is billed when a DEXA scan also includes an assessment of both axial bone density and vertebral fractures through dual-energy x-ray absorptiometry. This type of assessment reveals any vertebral fractures that may be present and coupled with bone density measures is of greater diagnostic usefulness and may warrant a higher reimbursement than a standard axial scan. Documentation is required to support all of the components of the procedure to justify the billing of CPT 77085.
Importance of Accurate Documentation
Supporting Medical Necessity
It is DEXA scan reimbursement that medical necessity is focused on the most. In the documentation, the patient’s diagnosis, medical history, relevant symptoms, risk factors, and treatment plans should be outlined. Patients may qualify if they are diagnosed with osteoporosis and/or osteopenia, have had past fractures, experience estrogen deficiency, or have received long-term steroid treatment.
If unclear documentation is attached to a claim, it may be denied, and can also cause issues with payment or reimbursement. This is why it’s important that providers align the physician orders, clinical documentation, and diagnostic notes to the CPT code.
Physician Interpretation and Reporting
While billing DEXA scans, there must be a formal report and interpretation by a physician and that must be included in the report. This report must include measurements of bone density, T-scores, clinical recommendations, and comparisons of the previous studies if any. This is documentation of the performance of the service’s professional component. In the absence of adequate medical reporting and interpretation, there is the possibility of a reimbursement not being complete or denied.
Modifiers Used in DEXA Scan Billing
Modifier 26: Professional Component
A modifier 26 is used when there is only the physician’s interpretation and reporting. This is often the case when a facility owns the imaging equipment but the physician’s interpretation is provided. Therefore, the modifier 26 is used to capture reimbursement for the professional component only. In the documentation, it has to show the physician’s details of the interpretation and reporting.
Modifier TC: Technical Component
Modifier TC applies to the technical component part of the DEXA scan billing. This covers the use of the equipment, technician service, and performing the images. It is common practice for facilities to apply this modifier for billing separate from the physician’s professional component. Billing modifier TC accurately is the key to getting reimbursed for the technical service.
Modifier 59: Distinct Procedural Service
Modifier 59 applies to DEXA scans when it is performed together with other imaging services on the same date. It indicates the services are separate and distinct. This modifier is used to avoid claim bundling and denials inappropriately. Providers must ensure that documentation supports the distinct nature of the services.
Medicare Coverage and Frequency Guidelines
Medicare Eligibility Criteria
Medicare covers DEXA scans for eligible individuals based on specific criteria. These criteria include postmenopausal women with an increased risk of developing osteoporosis, individuals with certain vertebral abnormalities, patients on long-term steroid therapy, and those diagnosed with primary hyperparathyroidism.
Supporting documentation from a physician and the corresponding ICD-10 diagnosis codes are required to substantiate the claims.
Limitations on Tests Coverage
Eligible beneficiaries can have DEXA scans done on an annual basis, but Medicare patients can only have them covered every two years unless it’s for an osteoporosis treatment, in which case it may be required to be done more often. If an office billed for DEXA scans more than every two years on a patient without a valid reason, it can trigger audits or denied claims.
Reimbursement Considerations for DEXA Scan Billing
Payer-Specific Requirements
Each payer has its own specific set of policies to apply to scanning a DEXA or bone density test. All policies can include rules on coverage and policies such as documentation needs, as well as rules on reimbursement amounts. It’s important that each office knows the rules for each payer prior to charging to prevent denied claims. Knowing specific rules for each payer helps to charge and reduces errors.
Accurate Coding and Claim Submission
Submitting claims and coding correctly is important for each payer to receive reimbursement. Each office has to have the same payer guide to provide a basis for the documentation of each. Modifier and code use is critical for reimbursement. Claims must be complete and accurate prior to submission.
Each billing office must charge for each product’s service; an audit can be triggered by incorrect claims. Each provider should ensure that the code selected to act out their service is indeed the code that they would document.
Common Billing Errors and How to Avoid Them
Incorrect CPT Selection
One of the most common billing errors that leads to a denied claim is incorrect CPT code use. It is the provider’s responsibility to ensure that the CPT code chosen describes the service accurately.
Missing or Incorrect Modifiers
Modifiers can mean the difference between getting or not getting paid. Staff billing needs to know the specific cases in which modifiers become necessary.
Lack of Medical Necessity Documentation
Claims without adequate documentation, especially that explains why the treatment was medically necessary, are routinely denied. Providers must document all clinical data.
Frequency Violations
Billing DEXA scans more than allowed and not justifying the overbilling can mean denials and audits. Providers need to comply with the payer’s frequency rules.
Strategies to Improve DEXA Scan Billing and Reimbursement
Staff Education and Training
Adequate training helps billing staff deal with CPT codes, modifiers, and documentation. Frequent training helps to cut errors and improves billing.
Verification of Insurance Coverage
Confirming the patient’s coverage and eligibility helps to avoid reimbursement problems. This ensures that the service is necessary and is covered.
Internal Audits and Compliance Monitoring
Conducting regular internal audits helps in identifying billing errors and in compliance, to avoid correcting problems before they become a financial loss or regulatory loss.
Compliance and Audit Risk Management
Billing for DEXA scans is audited by both Medicare and other insurance payers. Therefore, providers need to have complete and precise documentation justifying services provided. When coding, adhering to guidelines, and factoring in payer policies, it will lessen the chance of being audited and guarantees proper reimbursement.
Organized medical records, accurate coding, and correct use of modifiers will safeguard healthcare providers from the financial and legal ramifications of their actions.
Final Thoughts
In order to properly bill DEXA scans, one must have an in-depth knowledge of the associated CPT codes, the various modifiers, documentation needs, and policies of the payer. Correct coding to represent the correct procedure performed is associated with CPT codes 77080, 77081, and 77085. Modifiers 26, TC, and 59 are appropriate modifiers to bill the professional and technical components. Adequate documentation of the medical necessity, and the frequency with which Medicare guidelines are compliant will provide for reimbursement. Following the healthcare provider guidelines, checking insurance coverage prior to billing, and consistent compliance will lessen the rate of denials, increase reimbursement, and will provide efficient billing for DEXA scans.
Make An Appintment With A2ZFAQs
The most common CPT code is 77080 which is used for bone density testing for the axial skeleton and covers fully for imaging, interpretation, and report from the physician when done as a complete study.
CPT code 77081 is used for peripheral DEXA scans, for example, the wrist, heel, or finger. This is mostly used for screening or if axial testing cannot be done, although reimbursement may be more restricted.
The common modifiers used are Modifier 26 for the professional component and Modifier TC for the technical component. These modifiers apply when the interpretation and the technical part are billed separately.
For eligible patients, Medicare covers DEXA scans only once every two years, however, more than once is covered if medically necessary, for example, monitoring treatment of ongoing osteoporosis.
One of the reasons is that there is no documentation that says the scan is medically necessary. Other reasons may be missing diagnosis codes, incomplete orders from the doctor, or inadequate allowed billing.