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Coding Osteoporosis and Osteopenia


Question

When a diagnosis of osteoporosis and osteopenia are found on a bone density study, is it appropriate to code both findings, or just the osteoporosis since it is the most severe finding?

Answer

There is no coding guideline or instruction that indicates that both cannot be coded however, you are correct that osteopenia is considered a precursor to osteoporosis and that osteoporosis is considered a disease process while osteopenia is considered a condition therefore the osteoporosis is the more severe finding.  Whether you decide to code both will be your decision.  You may also want to develop an internal coding policy if you decide not to code the osteopenia in the presence of osteoarthritis so that there will be no question if this issue comes up on an internal or external coding review.

Disclaimer: All articles intended for general consumption only and not as a recommendation for a specific situation. Readers should consult an official source (AHA, AMA, etc.) or a qualified attorney for specific legal guidance.
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