Advances favor testing to gauge osteoporosis risk: new ICD-9 code, expanded indications for BMD tests may help detect abnormalities.

SANTA MONICA, CALIF. -- Clinicians can expect more information about their patients' bone health after referring them for dual-energy x-ray absorptiometry screening.

That's because a new ICD-9 code will soon reimburse radiologists for assessing incidental vertebral fractures along with bone mineral density.

And in another development, the International Society for Clinical Densitometry (ISCD) now advocates expanded screening for osteoporosis. In addition to traditional categories of individuals at risk, the expanded list of indications includes three new categories: men aged 70 years and older, adults with a fragility fracture, and adults with a disease or condition associated with low bone mass or bone loss.

At a symposium sponsored by the American College of Rheumatology (ACR), speakers said that these advances show heightened support for early identification of patients at risk for bone loss and associated fractures.

A key development is recognition of the importance of incidental vertebral fractures, said Dr. Paul Miller of the Colorado Center for Bone Research in Lakewood. Patients with one vertebral fracture are four times more likely than others to have a subsequent vertebral fracture. But the presence of incidental fractures on dual-energy x-ray absorptiometry (DXA) scans or plain radiographs often is overlooked, he said.

The ACR, the American College of Radiology, and the ISCD recently pressed for a new ICD-9 code providing reimbursement for incidental vertebral fracture assessment in patients with certain indications, such as loss of 4 cm or more in height after age 60.

Details about the new code, which will allow reimbursement above the amount billed for an eligible DXA scan ordered to assess bone mineral density, will be announced soon, Dr. Miller said. "This will take the field a step further because we are clearly underidentifying patients with prevalent vertebral fractures."

Central DXA machines now contain software systems that make accurate assessments possible. "You can assess the vertebral bodies with DXA in a resolution that is nearly as good as lateral thoracic lumbar spine films," he said.

Dr. Miller and Dr. Margaret Seton of Massachusetts General Hospital, Boston, welcomed most of the new official positions adopted by the ISCD and published in its journal (J. Clin. Densitom. 7[1]:1-6, 2004). The recommendations include more "at-risk" categories for osteoporosis screening than guidelines by the United States Preventive Services Task Force, the National Osteoporosis Foundation, or the American Association of Clinical Endocrinologists.

The ISCD also recommended using a uniform white female and male normative database as a reference point when calculating the T score of a patient of any race, rather than trying to adjust standard deviations to account for race. In America, intermarriage makes race-specific norms unnecessary for the purpose of calculating T score, a panel of ISCD experts said.

World Health Organization criteria should not be used to diagnose osteoporosis or osteopenia using peripheral bone densitometry, except for the 33% radius of the nondominant forearm, the ISCD panel concluded. Peripheral densitometry techniques are roughly as accurate as central DXA--reflecting true BMD rather than fat tissue, for instance--but are far less precise and reproducible. Dr. Seton explained.

The ISCD calls on every DXA center to determine its precision error rate and report its least significant change (LSC) score. This will help reassure physicians interpreting DXA results that they reflect a patient's true condition.

Peripheral devices, according to the ISCD, can be useful in assessing fracture risk, and, theoretically, could be used to identify patients who are unlikely to have osteoporosis, but they should not be used to monitor response to treatment.

Every patient should be measured at the posterior-anterior spine and hip, with the diagnosis made on the basis of the site with the lowest T score, according to the ISCD panel. The forearm should be used only if the hip and/or spine cannot be measured or interpreted, if the patient is "very obese," or in cases of hyperparathyroidism.

RELATED ARTICLE: Indications for Doing BMD Testing

The official position of the International Society for Clinical Densitometry is that a BMD test is indicated for these groups:

* Women aged 65 years and older.

* Postmenopausal women younger than 65 years with risk factors.

* Men aged 70 years and older.

* Adults with a fragility fracture.

* Adults with a disease or condition associated with low bone mass or bone loss.

* Adults taking medications associated with low bone mass or bone loss.

* Anyone being considered for pharmacologic therapy for low bone mass or bone loss.

* Anyone being treated for low bone mass or bone loss, to monitor treatment effect.

* Anyone not receiving therapy in whom evidence of bone loss would lead to treatment.

Source: The International Society for Clinical Densitometry

BY BETSY BATES

Los Angeles Bureau