Rheumatology Coding Corner Answer: Office Visit with DEXA Scan

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CPT: 99213-25, 77085
ICD-10: Diagnosis M81.0, Z79.52

The encounter is coded as 9913 as follows:

• History—The history of the present illness was extended. The review of systems was complete, and the past medical history was documented. This makes the history detailed.
• Examination—The examination was expanded problem focused.
• Medical decision making—The diagnosis was an established problem worsening; an X-ray was ordered and her prescription drugs were managed.

77085: Dual-energy X-ray absorptiometry (DEXA), bone density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine), including vertebral fracture assessment. Current Local Coverage Determination states the following: “A patient being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy. This service must be performed using dual-energy X-ray absorptiometry system (axial skeleton)—CPT codes 77080 and 77085.”

M81.0 is age-related osteoporosis without current pathological fracture. Z79.52 is long-term (current) use of systemic steroids.