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Varied Medicare reimbursement for bone density scans may be due to lack of clear diagnostic codes for test indications

Research Activities, August 2009, No. 348

More guidance and transparency in diagnostic coding are needed to ensure that Medicare patients with appropriate indications for central dual-energy x-ray absorptiometry (DXA) and other bone mass measurement tests are reimbursed for them, so that access to this important service is not compromised, recommends a new study. The Bone Mass Measurement Act (BMMA) of 1997 authorizes reimbursement for DXA and other bone mass measurement testing for five indications for U.S. Medicare beneficiaries. These include primary preventive screening for estrogen-deficient women, long-term glucocorticoid therapy, and hyperparathyroidism (conditions that all lead to loss of bone mass). Other indications are bone abnormalities such as vertebral fractures and assessment of patient response to approved medications for osteoporosis.

In 2005, DXA was covered as part of the "Welcome to Medicare" exam and may be repeated as a reimbursable exam as often as every 23 months, or more often for medical necessity. Yet many of these indications don't map to specific ICD-9 diagnosis codes, note the study authors. They analyzed Medicare claims data from 1999 to 2005 for a 5 percent national sample of elderly beneficiaries with part A and B coverage who were not in HMOs. Denial of Medicare reimbursement for these covered indications varied significantly by sex, time since previous DXA, diagnosis code submitted, place of service (office vs. DXA facility), and local Medicare carrier. For individuals who had no DXA in 1999 or 2000 and who had one in 2001 or 2002, the proportion of DXA claims denied was 5.3 percent for women and nearly twice that (9.1 percent) for men.

About 19 percent of claims for repeat DXAs (for men or women) performed within 23 months were denied. Reimbursement varied based on what diagnosis code was submitted. For repeat DXAs performed within 23 months from the most recent DXA, the proportion of claims denied ranged from 2 to 43 percent, depending on the Medicare carrier. The study was supported in part by the Agency for Healthcare Research and Quality (HS16956).

See "Regional variation in the denial of reimbursement for bone mineral density testing among U.S. Medicare beneficiaries," by Jeffrey R. Curtis, M.D., M.P.H., Andrew J. Laster, M.D., C.D.D., David J. Becker, Ph.D., and others, in the Journal of Clinical Densitometry: Assessment of Skeletal Health 11(4), pp. 568-574, 2008.

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Page last reviewed August 2009
Internet Citation: Varied Medicare reimbursement for bone density scans may be due to lack of clear diagnostic codes for test indications: Research Activities, August 2009, No. 348. August 2009. Agency for Healthcare Research and Quality, Rockville, MD.