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 therapyThe 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 //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 //www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1525.pdf.
Medicare covers DXA Bone Densitometry for certain Medicare beneficiaries who fall into at least one of the following categories:
1.) A woman whose doctor has determined she’s estrogen-deficient and at a clinical risk for osteoporosis, based on her medical history and other findings.
2.) Patient with vertebral abnormalities as demonstrated by x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture.
3.) Patient receiving or expecting to receive glucocorticoid (steroid) therapy equivalent to an average of 5.0mg of prednisone, or greater per day for more than 3 months.
4.) Patient with primary hyperparathyroidism.
5.) Patient being monitored to assess their response to or efficacy of an FDA-approved osteoporosis drug therapy.
Medicare beneficiaries who meet the above criteria may have a Diagnostic DXA once every 24 months (more often if medically necessary).
In addition to the many ICD-10 codes for fracture, the following diagnosis codes, when used with a DXA Bone Scan (77080) will be accepted and paid by Medicare:
"Present On Admission" is defined as present at the time the order for inpatient admission occurs — conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA.
- Z13.820 is considered exempt from POA reporting.
- 951 Other factors influencing health status
Convert Z13.820 to ICD-9-CM
Code History- 2016 (effective 10/1/2015): New code (first year of non-draft ICD-10-CM)
- 2017 (effective 10/1/2016): No change
- 2018 (effective 10/1/2017): No change
- 2019 (effective 10/1/2018): No change
- 2020 (effective 10/1/2019): No change
- 2021 (effective 10/1/2020): No change
- 2022 (effective 10/1/2021): No change
- 2023 (effective 10/1/2022): No change
- Screening (for) Z13.9
ICD-10-CM Diagnosis Code Z13.9
Encounter for screening, unspecified
- 2016 2017 2018 2019 2020 2021 2022 2023 Billable/Specific Code POA Exempt
- musculoskeletal disorder Z13.828
ICD-10-CM Diagnosis Code Z13.828
Encounter for screening for other musculoskeletal disorder
- 2016 2017 2018 2019 2020 2021 2022 2023 Billable/Specific Code POA Exempt
- osteoporosis Z13.820
- musculoskeletal disorder Z13.828
ICD-10-CM Codes Adjacent To Z13.820
Z13.6 Encounter for screening for cardiovascular disorders
Z13.7 Encounter for screening for genetic and chromosomal anomalies
Z13.71 Encounter for nonprocreative screening for genetic disease carrier status
Z13.79 Encounter for other screening for genetic and chromosomal anomalies
Z13.8 Encounter for screening for other specified diseases and disorders
Z13.81 Encounter for screening for digestive system disorders
Z13.810 Encounter for screening for upper gastrointestinal disorder
Z13.811 Encounter for screening for lower gastrointestinal disorder
Z13.818 Encounter for screening for other digestive system disorders
Z13.82 Encounter for screening for musculoskeletal disorder
Z13.820 Encounter for screening for osteoporosis
Z13.828 Encounter for screening for other musculoskeletal disorder
Z13.83 Encounter for screening for respiratory disorder NEC
Z13.84 Encounter for screening for dental disorders
Z13.85 Encounter for screening for nervous system disorders
Z13.850 Encounter for screening for traumatic brain injury
Z13.858 Encounter for screening for other nervous system disorders
Z13.88 Encounter for screening for disorder due to exposure to contaminants
Z13.89 Encounter for screening for other disorder
Z13.9 Encounter for screening, unspecified
Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.