Do You Need To Add a Modifier To One Of The Codes?

Published: 01st March 2011
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Our center provides DXA screenings to some cancer patients. We have been getting denials from Medicare on those claims where we code both 77080 and 77081. Is it required to add a modifier to one of the codes?



Well, it all depends on your payer whether you may report both studies together. CMS has a mutually exclusive edit (ME) that places 77081 (Dual-energy X-ray absorptiometry [DXA], bone density study, 1 or more sites; appendicular skeleton [peripheral] example., radius, wrist, heel]) in column 1 and 77080 ( axial skeleton [example., hips, pelvis, spine]) in column 2. The edit has a modifier indicator of 1.



According to Chapter 9, section H.14, of the National Correct Coding Initiative Policy (NCCI) Manual, "Even though it may be medically reasonable and essential to report both axial and peripheral bone density studies on the same date of service (DOS), NCCI edits prevent the reporting of multiple CPT codes for the axial bone density study or multiple CPT codes for the peripheral site bone density study on the same DOS.



This means that you should be able to add modifier 59 Distinct procedural service) to override the edit when you meet the "reasonable and necessary" criteria.



Area of concern: You'll need to check your payer's policy on when it considers 77080 and 77081 carried out on the same date to be reasonable and necessary.



For instance, WPS Medicare states, "Medicare will not reimburse for both axial and appendicular testing on the same DOS or within 30 days of each other, unless the medical records substantiate that the BMM initially obtained was not readable. Conditions that verify to Medicare that a BMM is not readable and a second BMM is medically necessary include documentation the patient has artificial instrumentation in place in either hip or spine, or for that matter other conditions that prevent a reading in those locations.



If you meet the requirements for medical necessity for the second study, choose 77081 and add modifier 59 to 77080.



For additional information on Medicare's measurement requirements, stay tuned to a medical coding guide like Supercoder!




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