Low bone density and osteoporosis are silent threats looming over individuals, leading to a higher risk of fractures. Mostly, these conditions go unnoticed without symptoms. However, proactive screening is a vital part of an effective preventive care strategy.
The procedure covered under CPT code 77080 is one of the integral diagnostic services that physicians employ. However, billing and reimbursement for these diagnostic scans can be a complex and confusing process for healthcare providers.
Our billing experts at MediBillMD penned this comprehensive guide to help you overcome the billing challenges. It discusses everything from applicable modifiers to clinical scenarios and reimbursement guidelines.
So, without further ado, let’s get started!
CPT Code 77080 – Description
CPT code 77080 covers dual-energy X-ray absorptiometry (DXA) of one or more bony areas on the trunk. It is an imaging procedure that assesses the bone mineral density (BMD) and helps in the diagnosis of osteoporosis or osteopenia.
For context, in osteopenia, bone density is low, but not low enough to be classified as osteoporosis. Think of it as an early stage (warning sign) that may lead to osteoporosis.
Contrarily, osteoporosis is a more severe condition in which bone density is significantly low, making bones fragile and prone to fracture.
Did you know that, on average, 10 million people in the U.S. have osteoporosis, and another 44 million individuals have low bone density, placing them at a higher risk.
What’s more alarming is that among the 10 million individuals with osteoporosis, 80% are women.
Scenarios Where CPT Code 77080 is Applicable
Let’s review some real-world clinical scenarios where CPT 77080 applies:
Routine Screening for a Postmenopausal Woman
Picture a 59-year-old postmenopausal female patient with no previous history of osteoporosis. She visits the clinic for a routine BMD screening.
Note that the patient has no symptoms. However, given her age and gender, the physician orders a DXA scan (CPT code 77080) for her hip and spine. It is a part of a preventive measure to establish a baseline and assess for age-related bone loss.
Monitoring a High-Risk Patient
Assume a 48-year-old male patient with a chronic inflammatory condition. He has been on long-term corticosteroid therapy. Hence, he is sent for a DXA scan (CPT code 77080).
The reason? Corticosteroids are a known risk factor for bone loss. Therefore, the physician orders a scan of the hip and spine. The findings will help monitor drug-treated osteoporosis while establishing a baseline BMD for future comparison.
Osteoporosis Treatment Monitoring
Imagine a 72-year-old female patient who was diagnosed with osteoarthritis two years ago. Since then, she has been on bisphosphonate medication.
For her follow-up appointment, the physician recommended a recent DXA scan (CPT code 77080). The scan will help the provider monitor the effectiveness of the treatment by assessing whether the bone mineral density has improved.
Applicable Modifiers for CPT Code 77080
The following are some of the applicable modifiers for accurately billing a DXA scan:
Modifier 26
Append modifier 26 to CPT code 77080 when the physician only interpreted the DXA scan images. It indicates to the payer that you are billing only for the professional component of the service.
Modifier TC
Facilities often use the modifier TC since they own the equipment, resources, and technical expertise needed to perform the DXA scan. It indicates that you are billing only for the technical component of CPT code 77080.
Modifier XU
What happens when you perform a DXA scan on the trunk with other significant and distinct procedures for the same patient on the same day? You append modifier XU to CPT code 77080 to indicate that it is an unusual, non-overlapping service. It helps you bypass National Correct Coding Initiative (NCCI) edits.
CPT Code 77080 – Billing & Reimbursement Guidelines
Discussed below are the essential billing and reimbursement guidelines related to the DXA scan:
Demonstrate Medical Necessity
Medicare and other payers will only reimburse for the DXA scan (CPT code 77080) when it is medically necessary. Men aged 70 or older, or women aged 65 or older, are eligible for routine screening. However, women aged below 65 and men aged 50-70 must have any of the following risk factors:
- A family history of osteoporosis.
- Patients with a fracture history after the age of 50.
- Individuals with eating disorders, significant height loss, or early menopause.
- Individuals undergoing long-term steroid therapy (over 3 months).
- People with a known diagnosis of chronic kidney disease (CKD) or rheumatoid arthritis.
- Individuals who regularly smoke or drink alcohol.
- Patients with a history of hormone treatment for prostate or breast cancer.
Note: Your medical claim must include a supporting ICD-10 diagnosis code corresponding to one of these clinical indications.
Meet the Documentation Requirements
Accurate coding is essential. However, without comprehensive documentation, the payer will not process your claim, resulting in denial or payment delays. Thus, if you want a steady revenue cycle, your documentation must include:
- The healthcare provider’s order for the DXA scan.
- Detailed explanation of the reason behind ordering the DXA scan. These include the patient’s medical history, symptoms, and supporting diagnosis.
- DXA scan report with physician interpretation and recommendations.
Understand Payer-Specific Policies
Payer guidelines related to CPT code 77080 significantly vary. Therefore, it is advisable to communicate with the relevant payer, acquire prior authorization, ask about frequency limitations, and comply with the billing requirements. It will help you prevent denials and ensure a healthier revenue cycle.
Summary
Here we come to the end of the detailed guide! But before wrapping up and saying adieu, let’s recap everything that we learned related to CPT code 77080.
First, we explained the descriptor. It covers DXA of one or more bony areas on the trunk. It involves determining the BMD and helps in the diagnosis of osteoporosis or osteopenia.
Next, we covered some real-world clinical scenarios where CPT 77080 applies. These include monitoring a high-risk patient, osteoporosis treatment monitoring, and routine screening for postmenopausal women.
We also shared the applicable modifiers to help you accurately bill for DXA scans, including 26, TC, and XU.
Finally, we discussed the key billing and reimbursement guidelines related to CPT 77080.
Hopefully, this guide will become your go-to resource for billing DXA scans. However, if you still find it challenging to navigate the complex billing requirements, feel free to outsource radiology billing services to MediBillMD.
