Dual-energy x-ray absorptiometry, also called bone mass measure, is very important in the identification and monitoring of osteoporosis as well as other diseases of the bones. Code 77080 is assigned to a central DEXA, which is a non-invasive test used to determine the patient’s BMD. DEXA is a useful tool for diagnosing osteoporosis, assessing the chances of bone breakages, and evaluating the impacts of the implemented treatment plan. In this informative article, you will find information about CPT Code 77080, different diagnosis codes, reimbursement policies, and other billing peculiarities.
Healthcare professionals depend on coding to get the right amount of revenue for services they have duly offered. Therefore, it is crucial for healthcare professionals to comprehend specific details about CPT Code 77080 and submission billing rules to avoid claim rejections and adhere to Medicare and private insurance policies.
Overview of CPT Code 77080
77080 CPT code is regarded as the code for central DEXA, which is an imaging test aimed at the analysis of bone density. This scan mainly quantitates the mineralization of the vertebrae in the lumbar region, the femoral shaft, and, in some cases, the radius. DEXA scan is a procedure that helps in identifying disorders such as osteoporosis or osteopenia and further measures the likelihood of bone fractures that result from bone density reduction. Therefore, the code is a useful tool for all best healthcare providers who are involved in the screening, diagnosis, and management of osteoporosis.
77080 CPT code description and Use
In the DEXA scan, two beams of different energy pass through the body. Critical assessment of the measure of X-ray that the bones have absorbed enables the doctor to determine the bone density against that of normal density of bones belonging to healthy people.
The primary role of the CPT 77080 scan is to diagnose osteoporosis or evaluate the risk of fracture in patients who are prone to bone diseases. This scan is useful to determine the weakness of bones so that the patient can be advised of the required precautions or treatments. Code 77080 specifically takes into account the central bone density of an area, including the spine and hip region. These are the most commonly affected areas when it comes to bone-related diseases such as osteoporosis.
Who Should Get a DEXA Scan?
Some persons require a DEXA scan to assess their bone density. There are several cases in which performing this test is possible, and it would be beneficial for the following patients:
- Women who have gone through the menopausal stage, especially those who have a background of osteoporosis or femoral fractures.
- People who suffer from ailments that may require the use of steroids that may alter bone mass density.
- It was for patients of the lower age with severe osteoporosis, considerable bone loss, or fractures.
- People who are suffering from certain illnesses such as rheumatoid arthritis or hyperthyroid diseases that would lead to emaciation bones.
77080 CPT Code Reimbursement Medicare
Medicare Coverage Criteria
Medicare covers CPT Code 77080 for bone density screening if certain criteria are met. These vulnerable populations and volunteers are defined as periods that include patients who are at risk of osteoporosis or fractures. First of all, Medicare will cover the following circumstances for a DEXA scan:
- The patient is a woman of more than 65 years of age or a man of over 70 years of age with symptoms of risk factors.
- Cortisol Patient is covered with features such as a family history of fractures, osteoporosis, use of corticosteroids, and earlier bone fracture.
Reimbursement Rates and Policies
The amount payable by Medicare with regarding CPT Code 77080 may also differs from one geographical area to the other depending on the Medicare Administrative Contractor it deals with. This could also be possibly translated as the reimbursement rates may fluctuate from one year to the other. MACs or the NCCI must be consulted for the current rate to ensure correct billing of the services.
Factors Affecting Reimbursement
The following lists some of the elements that would determine the reimbursement, which can be encouraged by the 77080 CPT Code:
- Pre-authorization: In addition to prescription by the referrer, Medicare demands justification as to why the patient needs the DEXA scan. In case of any ambiguity, it is usually possible that claims will not be entertained or granted as they should be.
- Frequency limitation: There are normally limitations to Medicare, the DEXA scan is allowed to be performed on the same patient, after two years at most. In any case, if the patient has high-risk factors, other tests may be allowed.
- Diagnosis codes: It will be important to submit valid ICD-10 diagnosis codes for the patient’s condition for Medicare. If one is in the habit of using improper or unsubstantiated codes, he is likely to be paid nothing or be given a scanty reward.
Diagnosis Codes for DEXA Scans (ICD-10)
To justify the imaging of the DEXA scan under the CPT Code 77080, the provider must present the appropriate ICD-10 codes. These codes relate to the patient’s condition and help them decide whether the scan is required. The following diagnosis codes are usually assigned to DEXA procedures:
- An experience of broken bones caused by osteoporosis or thinning of bones.
- Hormonal medications – those that may have adverse effects on bone density, such as prolonged use of corticosteroids.
- Such diseases as rheumatoid arthritis or hyperthyroidism cause the chances of getting osteoporosis.
These codes represent bone loss, prior fractures, and osteoporosis, which are among the reasons why a DEXA scan could be done.
Medical Necessity Requirements
Again, by Medicare, certain requirements have to be met to address medical necessity for CPT Code 77080 as follows;
- M81.0: Age-related osteoporosis without current pathological fracture.
- M85.8: Other specified disorders of bone density and structure.
- Z13.820: Screening for osteoporosis.
Preventive vs. Diagnostic DEXA Scans
Preventive Screening CPT Codes
It is worth mentioning that CPT 77080 is used in the diagnostic domain, but there are codes for preventative scans of DEXA. Preventive DEXA scan is likely to be embraced under Medicare, especially if the patient is postmenopausal or above the age of 65 and has no past history of osteoporosis. A preventive type usually falls under the annual or biannual screening. Medicare’s coverage for preventive screening of DEXA scans is normally permissible for two years. Most of the scans are important in preventing bone loss as they can call for early treatment by using medications or altering certain operations in a patient’s lifestyle.
Difference between Preventive and Diagnostic Billing
Preventive DEXA scans involve codes 77080, and they are performed on patients believed to be at risk for sustaining fractures or osteoporosis. These are put under preventive care codes and may not have similar billing codes.
Diagnostic DEXA scans (CPT Code 77080) are prescribed in cases where the doctor specifies any bone ailment/abrasions/breaks or when the patient has a medical condition that affects the bones. These are provided under the context of diagnosis and may be reimbursed more often depending on the patient’s situation.
Billing Guidelines for CPT Code 77080
Documentation Requirements
Documentation plays an important role when it comes to CPT Code 77080, especially when it comes to the matter of getting a reimbursement. Providers must include:
- Communicate patient history: The patient's age, sex, medical history, and history of chronic illnesses or other illnesses.
- Purpose of the scan: The DEXA scan is required for the patient because of prior breaks and medications that may affect bone density.
- Affected bones assessment: You should specify if it affected the spine, hip, or other bones.
Modifiers That May Apply
- With this procedure, there are certain modifiers that should be noted when billing for CPT Code 77080; they include:
- Modifier 26: Only used if the professional component of the DEXA scan is submitted (i.e., interpretation of results).
- Modifier TC: An added modifier in such situations when only the technical component is billed, for instance, when conducting the scan without the actual interpretation.
Common Billing Errors and How to Avoid Them
The billing errors that are often made while submitting the claims of CPT 77080 are as follows:
- The improper use of diagnosis codes: This is because it is possible to submit a diagnosis code that does not justify the need for a DEXA scan, hence leading to denials.
- Lack of use of appropriate modifiers: The correct modifier must be chosen depending on whether the service is considered professional or technical.
- Incorrect frequency billing: A discrepancy in billing for scans taken in a short interval or before two years may result in the claim being rejected.
Frequency of Billing for CPT Code 77080
How Often Can 77080 Be Billed?
Medicare allowed only CPT Code 77080, where a patient is entitled to one bone density test every two years. Nonetheless, the frequency may rise depending on some risk factors, such as whether the patient has had a previous fracture or is still on therapy for osteoporosis.
Medicare and Private Insurance Rules
Generally, different private insurance policies offer different coverage and are offered with varying frequency. Some may only allow scans on an annual basis or on a need-basis and may need prescriptive approval. It is, therefore, wise to normally check with the insurance provider for the specificities that should not be violated at any cost.
Appeals and Denials for CPT Code 77080
Claim denials are very common in the healthcare industry, and CPT 77080 also falls in the same bracket. Common reasons for denials include:
- Lack of medical necessity documentation.
- Incorrect ICD-10 codes or modifiers.
- Frequency-related concerns: Scans asked for too often, which will imply denial.
Steps to Appeal a Denied Claim
- There must be a record of denial letters, meant to be read to determine the cause of the rejection.
- Several documents are required in support of this assertion that the scan is medically necessary.
- The claim should be submitted again with the right diagnostic codes and, if needed, some changes.
Conclusion
CPT Code 77080 plays a crucial role in bone density assessment and diagnosing osteoporosis and other bone-related conditions. In this case, it is crucial to understand the right use of this code to be compensated or paid for the services provided or risk having the claims denied. Medicare and private insurance policies should be implemented and documented properly to enhance reimbursement rates for DEXA scans and patient care.
FAQ - People Also Asks
What does CPT Code 77080 mean?
CPT Code 77080 pertains to a central DEXA that is used to determine bone mineral density in the spine and hip, for instance, to identify osteoporosis.
What diagnosis codes cover a DEXA scan?
- M81.0 – Age-related osteoporosis.
- M85.8 – Bone density disorders.
- Z13.820 – Osteoporosis screening.
What is the CPT Code for preventive DEXA scan?
The code 77080, on the other hand, is used in preventive DEXA scans usually done on high-risk subjects.
How often can 77080 be billed?
The above code CPT 77080 can be billed twice in a two-year period in the case of Medicare, but the highly risky patients may warrant more frequent scans.