DEXA scan (Dual-Energy X-ray Absorptiometry), also known as a bone density test, is a diagnostic procedure used to measure bone mineral density. Clinicians use DEXA scans to diagnose osteoporosis, assess fracture risk, and monitor treatment effectiveness. Healthcare professionals documenting DEXA scan results and medical coders should understand the relevant clinical terminology and coding guidelines for accurate reporting. Find information on DEXA scan procedure codes, interpretation, and best practices for bone health assessment and documentation.
Also known as
Encounter for screening for osteoporosis
Encounter for bone density screening using DEXA.
Disorders of bone density and structure
Includes osteoporosis, osteopenia, and other bone density issues.
Osteoporosis without current pathological fracture
Diagnosis of osteoporosis confirmed by DEXA scan, no fracture.
Osteoporosis with current pathological fracture
Osteoporosis with fracture, often diagnosed with DEXA.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is DEXA scan for screening purposes?
Yes
Code Z13.820, Encounter for screening for osteoporosis
No
Is there a diagnosed condition?
When to use each related code
| Description |
|---|
| Measures bone mineral density. |
| X-ray imaging of bones. |
| Blood test measuring calcium levels. |
Coding a DEXA scan without specifying the fracture type (e.g., compression, stress) if present, leads to inaccurate severity reflection and reimbursement.
Incorrectly coding osteopenia as osteoporosis or vice-versa based on DEXA results can impact medical necessity reviews and patient management.
Failing to code underlying conditions or symptoms justifying the DEXA scan (e.g., back pain, family history) can trigger claim denials.
Q: How to interpret DEXA scan T-scores and Z-scores for osteoporosis diagnosis and fracture risk assessment in postmenopausal women?
A: Interpreting DEXA scan T-scores and Z-scores is crucial for accurate osteoporosis diagnosis and fracture risk assessment, especially in postmenopausal women. A T-score compares the patient's bone mineral density (BMD) to the average BMD of a young, healthy adult of the same sex. A T-score of -1.0 or above is considered normal. Osteopenia is diagnosed with a T-score between -1.0 and -2.5. Osteoporosis is diagnosed with a T-score of -2.5 or below. Z-scores, on the other hand, compare the patient's BMD to the average BMD of individuals of the same age, sex, and ethnicity. A significantly low Z-score (typically below -2.0) may suggest a secondary cause of bone loss requiring further investigation, even if the T-score is not in the osteoporotic range. Consider implementing a comprehensive fracture risk assessment tool, such as the FRAX tool, which incorporates clinical risk factors along with BMD, to provide a more personalized estimate of fracture risk. Explore how integrating these scores with patient history and other clinical findings can enhance osteoporosis management. Learn more about the latest guidelines for osteoporosis screening and treatment from organizations like the National Osteoporosis Foundation (NOF).
Q: What are the best practices for DEXA scan ordering and referral for suspected secondary osteoporosis in men?
A: DEXA scan ordering and referral practices for suspected secondary osteoporosis in men should consider several factors beyond just age. While age-related bone loss is common, secondary osteoporosis can be caused by various underlying conditions such as hypogonadism, glucocorticoid use, malabsorption syndromes, and certain medications. Clinicians should consider a DEXA scan for men with risk factors for secondary osteoporosis, including those with a history of fragility fractures, low body weight, or conditions associated with bone loss. When interpreting results, a low Z-score in addition to a low T-score warrants further investigation to identify the underlying cause. In such cases, referral to an endocrinologist or other relevant specialist may be necessary to manage the underlying condition and optimize bone health. Explore how incorporating a thorough patient history and physical exam can help identify potential secondary causes. Consider implementing a standardized referral process to ensure timely and appropriate management of men with suspected secondary osteoporosis.
Patient presented for a Dual-Energy X-ray Absorptiometry (DEXA) scan to assess bone mineral density (BMD) and evaluate osteoporosis risk. The indication for the DEXA scan included [Specify indication e.g., family history of osteoporosis, low body weight, prolonged corticosteroid use, postmenopausal status, previous fracture]. The patient's medical history is significant for [List relevant medical history, e.g., hypertension, hyperlipidemia, diabetes]. Current medications include [List current medications]. The patient denies any current fractures or significant bone pain. Prior to the scan, the patient confirmed no recent barium studies or nuclear medicine scans. The DEXA scan was performed on the [Specify body part, e.g., lumbar spine, hip, forearm] using standard protocols. The T-score obtained was [Insert T-score value]. The Z-score obtained was [Insert Z-score value]. Based on the DEXA scan results, the patient's bone density is classified as [Specify classification e.g., normal, osteopenia, osteoporosis]. A discussion regarding the results, including implications for fracture risk and recommended management strategies such as lifestyle modifications (diet, exercise, fall prevention), calcium and vitamin D supplementation, and potential pharmacologic interventions (bisphosphonates, denosumab), was conducted with the patient. Follow-up [Specify follow-up e.g., repeat DEXA scan, referral to endocrinology or rheumatology] is scheduled for [Date or time frame]. The ICD-10 code for this encounter is [Insert appropriate ICD-10 code, e.g., Z13.820, M81.0, M80.-].