2013 PQRS Aligns with Other Quality Reporting Programs

By Penny Osmon Bahr, BA, CPC, CPC-I, CHC, PCS

The 2013 Medicare Physician Fee Schedule (MPFS) final rule makes several changes to the Physician Quality Reporting System (PQRS). Providers who begin reporting now in accordance with these changes stand to gain incentive payments, while those who don’t will soon suffer economic consequences.

Incentives: The Good, the Bad, and the Ugly

The Good: Successful participation in the 2013 PQRS earns providers a 0.5 percent incentive on all original Medicare Part B allowed charges billed in the reporting period (whether six or 12 months). This incentive continues through 2014.

An additional 0.5 percent incentive is also available through 2014 for eligible providers (EPs) who submit data on quality measures through a Maintenance of Certification® (MOC) program operated by a specialty body of the American Board of Medical Specialties (ABMS). In addition to reporting PQRS data successfully for one year (submitted through a MOC program), the physician must participate in and successfully complete a MOC program. Board certification status may require more frequent reporting.

The Bad: Effective Jan. 1, 2015, EPs who do not successfully report PQRS quality measures will incur a negative 1.5 percent adjustment to all professional services reimbursed under the Medicare Part B fee schedule, based on 2013 program year data, per section 3002(b) of the Affordable Care Act (ACA).

The Ugly: Beginning in 2016, the negative adjustment to payments for nonparticipating EPs increases to 2 percent.

Subtle Changes to Traditional Reporting

The first step to successful PQRS participation is choosing “how” to report quality measures. An EP has two options: Either as an individual or as a group practice under the Group Practice Reporting Option (GPRO).

The 2013 MPFS final rule expands the definition of “group practice” from 25 or more EPs to two or more National Provider Identifiers (NPI) assigned to a single Tax Identification Number (TIN). Participation in the GPRO requires self-nomination. For 2013, GPRO reporters have until Oct. 15, 2013 to select and change their initial reporting method.

Individual EP Reporting of Individual Measures

EPs choosing to report as individuals must decide if they will report on individual measures or measures groups. Self-nomination is not required if an EP chooses individual reporting, regardless of the method of measure submission.

As shown in Table A on the next page, EPs choosing to report individual measures under their individual NPI may still choose from the following reporting mechanisms:

• Claims
• Registry
• Qualified direct electronic health record (EHR)
• Qualified EHR data submission vendor

Per the final rule, published in the Federal Register last Nov. 16, there are 259 measures for 2013, including 241 reportable through claims or registries.

Aligning Quality Initiatives

There are a number of quality improvement initiatives running concurrently that affect physician payments under Fee-for-Service Medicare, including the EHR incentive programs, Million Hearts Campaign, eRx program, Medicare Shared Savings Program (MSSP), and more. The 2013 MPFS final rule outlines PQRS changes intended to align quality-reporting requirements across these programs, thereby making it easier for EPs to earn incentives.

“We believe that alignment of CMS quality improvement programs will decrease the burden of participation on physicians and allow them to spend more time and resources caring for beneficiaries.”
— 2013 Medicare Physician Fee Schedule Final Rule

In 2012, the Centers for Medicare & Medicaid Services (CMS) began offering EPs attesting to meaningful EHR use the ability to “pilot” PQRS clinical quality measures reporting on the same sample of beneficiaries used for pursuing an EHR incentive payment. To participate in the EHR pilot program, EPs must indicate this intention through their meaningful use incentive program attestation.

As shown in Table B on the next page, EPs may choose to report the same six clinical quality measures for PQRS incentive purposes as they are reporting for meaningful EHR use. The six measures must include three core or alternate core EHR clinical quality measures and three additional EHR incentive program clinical quality measures. The clinical quality measures must be reported through direct EHR submission, or via a qualified data submission vendor. The pilot effectively allows “double dipping,” as EPs are able to capture one set of measures for use across two separate CMS quality incentive programs.

An EP choosing the EHR pilot must report on a full year of quality data and must be in his or her second year of meaningful use.

Individual EP Reporting of Measures Groups

EPs who opt for measures groups may submit through claims or a registry. A significant change to measures group reporting is the reduction of the patient sample threshold to 20 Medicare Part B FFS beneficiaries (down from 30).

There are 22 measures groups for 2013, including a new measures group for oncology, focused on measurement of breast and colon cancer screening. The community acquired pneumonia (CAP) measures group was retired. The final measures groups are:

• Diabetes Mellitus
• Chronic Kidney Disease
• Coronary Artery Bypass Graft (CABG)
• Preventive Care
• Rheumatoid Arthritis
• Perioperative Care
• Back Pain
• Coronary Artery Disease (CAD)
• Heart Failure
• Ischemic Vascular Disease (IVD)
• Hepatitis C
• HIV/AIDS
• Asthma
• Chronic Obstructive Pulmonary Disease (COPD)
• Dementia
• Sleep Apnea
• Irritable Bowel Disease (IBD)
• Parkinson’s
• Hypertension
• Oncology
• Cardiovascular Prevention
• Cataracts

CMS also finalized its intent to add Osteoporosis, Total Knee Replacement, Radiation Dose Optimization, and Preventive Cardiology as measures groups for reporting in 2014.

Group Practice Reporting

CMS finalized the proposal for groups of two or more NPIs to nominate and report under GPRO for 2013 quality reporting, providing greater opportunity for smaller clinics to participate in “system-based” reporting. Group practice size is determined during the active participation of reporting and not at the time of nomination.

Groups of two to 24 EPs looking to self-nominate under the GPRO must report on at least three measures through a registry on at least 80 percent of all Medicare FFS patients seen during the reporting period. The more common “web interface” reporting methodology associated with GPRO (more detail below) is not designed for smaller groups. CMS will not assign beneficiaries to groups of two to 24 that opt for GPRO reporting in 2013.

Registry reporting is a new reporting option for groups of 25-99 and 100+ EPs participating in GPRO for 2013. CMS will post a comprehensive list of quality registries on its website by summer 2013. When the registry reporting mechanism is selected, groups will choose three measures and report on 80 percent of all Medicare Part B FFS patients seen during the reporting period (Jan. 1, 2013 to Dec. 31, 2013).

Web interface is an alternative reporting mechanism with the number of assigned beneficiaries adjusted respective to group size. Groups of 25-99 will be assigned a Medicare patient sample of 218. Groups of 100 or more EPs will be assigned 411 patients. To continue alignment with other quality initiatives, CMS has adopted the Medicare Shared Saving Program (MSSP) method of patient assignment and sampling (For additional information on the MSSP program, go to www.federalregister.gov/articles/2011/11/02/2011-27461/medicare-program-
medicare-shared-savings-program-accountable-care-organizations). If either group fails to meet the sample threshold, they must report on 100 percent of the patient sample.

Regardless of size, if a group has chosen the web interface methodology, it must report on all 22 quality measures and seven disease modules: Care Coordination/Patient Safety, Preventive Care, Coronary Artery Disease, Diabetes Mellitus, Heart Failure, Hypertension, and Ischemic Vascular Disease.

If EPs are actively participating in a CMS Accountable Care Organization (ACO), they must report clinical quality measures through the GPRO web interface according to the ACO reporting criteria; they would not self-nominate for PQRS reporting through GPRO.

As CMS takes continued steps toward the public reporting of clinical quality data, EPs who actively report PQRS measures through the GPRO mechanism in 2013 will have their group level performance data posted on the Physician Compare website (www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Physi​cianReview-ICN904144.pdf).

There’s Still Time to Act

Through the final rule, CMS offers opportunities for EPs to successfully avoid the negative adjustment in 2015 and to prepare for the impact of the Value-based Payment Modifier, a provision of the ACA also mandated for implementation in 2015 (You can find additional information on the VBM at: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html).

Avoiding the PQRS Negative Adjustment

CMS is offering a temporary, less stringent data submission methodology for 2013, created to assist EPs in avoiding the 2015 PQRS negative adjustment. Unlike traditional clinical quality reporting, this methodology does not require EPs to submit any clinical quality data codes on Medicare Part B claims. Instead, CMS will analyze administrative claims data for 14 preventive and chronic care measures.

If EPs opt for the administrative claims methodology, they are required to self-nominate on the CMS website beginning summer 2013 (and no later than Oct. 15, 2013). Choosing the administrative claims option provides a mechanism for EPs to avoid the negative adjustment in 2015, but does not satisfy the reporting requirements for the PQRS incentive in 2013.

CMS provides EPs with three options for avoiding the 2015 PQRS payment adjustment:

1. Satisfactorily report and earn the 2013 incentive of 0.5 percent.
2. Report one valid measure or measures group using a traditional reporting methodology of claims, registry, or EHR.
3. Self-nominate for analysis by CMS under the administrative claims-based reporting methodology.

The Push for Better Care and Outcomes

CMS has moved again to better align quality-reporting requirements in an effort to minimize duplication and administrative burden and, ultimately, to increase participation rates. CMS will continue to modify and evolve quality initiatives like PQRS to collect accurate and meaningful data that will empower physicians, health care systems, and patients through information for the purpose of affecting overall care delivery and outcomes, and to influence the shift of paying for “value” vs. “volume.”

Penny Osmon Bahr, BA, CPC, CPC-I, CHC, PCS, is director of health care solutions and specializes in health care reimbursement and practice management. She has more than 18 years of health care experience with a strong background in Medicare compliance, coding and billing, regulatory interpretation, curriculum development, and health information management (HIM). Ms. Osmon Bahr provides strategic guidance and solutions for revenue cycle, ICD-10, risk management, and HIM for health care clients throughout Wisconsin and the Midwest, emphasizing waste reduction, risk mitigation, and quality improvement. She is an author and speaker. Ms. Osmon Bahr is a founding member of the Wisconsin ICD-10 task force (WICD-10), sits on the HIMSS national ICD-10 Task Force, and is a member of the Medical Group Management Association.

April 1st, 2013

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Fine Details Are Critical in Fracture Coding

By Ken Camilleis, CPC, CPC-I, CMRS, CCS-P

Analyze documentation to understand the intricacies of diagnostic and procedural fracture coding.

Because there are so many types of fractures and fracture treatments, appropriate diagnostic and procedural coding is very complex. Obtaining appropriate reimbursement in compliance with payer regulations and coding guidelines requires a thorough analysis of the documentation. Before you can do that, however, you have to understand what you’re looking at, and know which details you’re looking for.

Code by Location/Open or Closed

The formal definition of fracture in ICD-9-CM is, “a complete or incomplete break in a bone resulting from application of excessive force.” The ICD-9-CM Alphabetic Index (Volume 2) arranges fracture diagnosis codes alphabetically by location, and often by relative position of a given site (e.g., distal end or proximal end). For example, the entry “fracture; clavicle” contains codes specific to the interligamentous region, the acromial end, the shaft (middle third), and the sternal end of the bone.

The first three digits of a fracture diagnosis code identify the general location of the fracture (e.g., 800.xx-804.xx for skull fractures, 805.xx-809.xx for neck and trunk fractures, etc.). The fourth digit generally identifies the fracture as either open or closed. Open means there is a skin wound caused by the fracture. Closed means there is a breakage of bone but not of surrounding skin. If a fracture is not specified as either open or closed, you must assume it is closed, as indicated by an instructional note at the beginning of ICD-9-CM chapter 17, in the Fractures section (categories 800-829).

Most ICD-9-CM fracture diagnoses require a fifth digit. Typically, the fifth digit of a fracture repair diagnosis code indicates more specific bones within the general site, but may also indicate other specified information. For example, when coding for skull fracture (800.xx-804.xx), the fifth digit indicates if there was a loss of consciousness, how long it lasted, and whether there was a return to the previous level of consciousness. Clinicians should be careful to document these and other associated conditions (e.g., spinal cord injury).

Stress Fractures May Warrant Causation Codes

Clinicians and coders must often distinguish between traumatic fractures (caused by an acute injury), pathologic fractures (caused by an evolving disease process that weakens bone, such as osteoporosis), and stress fractures (due to repeated strain from overuse).

Traumatic fractures are reported from ICD-9-CM categories 800-829 while the patient is receiving active treatment, such as surgical or emergency department care. Aftercare treatment requires different codes (see “Fracture Aftercare Calls for Unique Coding” on page 42 for more detail).

To identify a pathologic fracture receiving active treatment, report 733.1x.

For example, a 58-year-old man is diagnosed with a pathologic fracture of his C6 spinous process. Because this is a pathologic fracture, the correct code is 733.13 Pathologic fracture of vertebrae.

If the same patient had suffered from a traumatic fracture, you would code from category 800-829. For the C6 spinous process, you would report 805.06 Fracture of vertebral column without mention of spinal cord injury; cervical, closed; sixth cervical vertebra.

A stress fracture, aka an insufficiency fracture, is caused by repeated strain from overexertion or due to a weakened bone (i.e., osteoporosis). Look to category 733.93-733.99 to report stress fractures. Also assign the appropriate diagnosis code to describe any underlying external cause.

For example: A 13-year-old boy was lifting heavy weights at his school’s gym when he began to clutch his left knee in pain. He was diagnosed with a stress fracture of his tibia shaft. Because this is a stress fracture rather than an impact fracture, and is specified as of the tibia, the proper code is 733.93 Stress fracture of the tibia or fibula. You must also specify the external cause of the stress fracture, including E927.0 Overexertion from sudden strenuous movement and E010.2 Activity involving other muscle strengthening exercises; free weights. You can also specify place of occurrence, E849.6 Place of occurrence; public building.

History of pathologic fracture or stress fracture, when documented, should be reported secondarily to the active fracture. The history codes are V13.51 Personal history of pathologic fracture and V13.52 Personal history of stress fracture.

Tips for Diagnosis Sequencing

ICD-9-CM Official Guidelines for Coding and Reporting (section I.C.17.b) stipulates three primary rules for assigning and sequencing fracture diagnoses:

1. Code all fractures separately. This includes multiple unilateral or bilateral fractures classified to different fourth-digit subdivisions (bone part) within the same three-digit category (bone).
2. Combination codes are used only for triage on patients with multiple injuries when the extent of the individual injuries is unknown prior to transfer of care.
3. Report multiple fractures by severity (most severe first), as determined by the treating physician.

For example, following a motor vehicle accident, the patient arrives in the emergency department with multiple open depressed skull and facial bone fractures, facial lacerations, and contusions. She has experienced a 90-minute loss of consciousness. The appropriate ICD-9-CM code is 804.63 Multiple fractures involving skull or face with other bones; open with cerebral laceration and contusion; with moderate [1-24 hours] loss of consciousness. In this case, a combination code may be used. The code also describes other, associated conditions (e.g., loss of consciousness).

CPT^® Coding for Fracture Treatment

“Fracture” appears in the CPT® Index as a main term (just as it does in ICD-9-CM). This is where you’ll begin your search for fracture treatment codes. The terms “fracture” and/or “dislocation” appear at the category level in the main section of the CPT® codebook. For example, codes 27750-27848 represent treatments of fractures of the tibia, fibula, and ankle joints.

There are three major approaches to treat fractures: closed, open, and percutaneous.

• Closed treatment means the fractured bone is not exposed to the view of the surgeon.
• Open treatment means the bone is exposed by incision.
• Percutaneous treatment (aka percutaneous skeletal fixation) involves the placement of a fixative device—such as a rod, wire, or pin—across the fractured bone usually under imaging guidance.

The treatment type will not necessarily match the fracture type. For instance, an orthopedic surgeon may perform an open treatment of a closed fracture, or a percutaneous treatment of either a closed or open fracture.

When coding for physician services for surgeries to correct fractures, pay particular attention to terms such as closed/open/percutaneous treatment and details describing the specific site (such as nasal bone, nasal septum, nasoethmoid, nasoethmoid complex, or nasomaxillary). You’ll also need to understand which combinations of terms are mutually exclusive with each of the three treatment methods. Read all CPT® descriptors carefully, noting terms such as “open reduction with internal fixation.” Observe when certain services (such as the application of the fixative device) are included in the descriptor, and not reported separately.

For both procedural and diagnostic coding, experts generally agree that if one bone is both fractured and dislocated, code only the service and diagnosis for the fracture and not the dislocation (see Coding Clinic, third quarter 1990, page 13). Some CPT® codes specifically describe surgeries on a bone that is both fractured and dislocated.

For example, an 87-year-old man with history of falling presents for repair of fractured proximal ulna and dislocated radial head. He slipped on ice, landing on his right elbow, and sustained a Monteggia fracture. The orthopedic surgeon performed an open reduction and internal fixation (ORIF) over the site.

The correct CPT® and ICD-9-CM codes to describe this scenario are:

• 24635-RT Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), includes internal fixation, when performed-Right side to describe the ORIF for Monteggia fracture.
• 813.03 Fracture of radius and ulna; upper end, closed; Monteggia’s fracture for the traumatic fracture. Because the fracture is not indicated as open, you would code it as closed.
• V15.88 History of fall indicates the patient has a history of falling.
• E885.9 Fall from other slipping, tripping, or stumbling describes a fall on same level, such as slipping.
• E849.0 Place of occurrence, home notes where the fracture occurred.

You would not code the dislocation because the same bone is also fractured.

In a second example, a 26-year-old woman is injured in a downhill skiing accident. She fractures and dislocates her left shoulder. The impact was to her left distal humerus, medial condyle. Using anesthesia, the orthopedic surgeon repairs her shoulder by reducing the fracture without directly visualizing the injured site.

The correct CPT® and ICD-9-CM codes are:

• 23665-LT Closed treatment of shoulder dislocation with fracture of greater humeral tuberosity, with manipulation; requiring anesthesia-Left side. Because the orthopedist performed the surgery without visualizing the fracture site, this is a closed treatment.
• 812.43 Fracture of humerus; lower end, closed; medial condyle. Do not code the dislocation as well because the fracture of the same bone is the more serious injury.
• E885.3 Fall from skis
• E003.2 Activities involving ice and snow; snow (alpine) (downhill) skiing, snow boarding, sledding, tobogganing and snow tubing

This is a lot of information to take in. In a nutshell, just remember: Diagnosis coding should report the location of the fracture, the severity of the fracture, and whether there were complications due to the fracture. Procedure coding should report the approach for treatment, the location being treated, and any extenuating circumstances due to treatment.

 Sidebar

Fracture Aftercare Calls for Unique Coding

Codes 800-829 for traumatic fractures, 733.1x for pathologic fractures, and 733.93-733.99 for stress fractures should be reserved for when the patient is receiving active treatment for the fracture. ICD-9-CM Official Guidelines for Coding and Reporting defines active treatment as “surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.”

When reporting services provided during the healing or recovery phase of the fracture, turn instead to fracture aftercare codes from category V54. Examples of aftercare include cast change or removal, removal of external or internal fixation devices, medication adjustment, and follow-up fracture treatment visits.

Sidebar

ICD-10-CM Ups the Documentation Ante

As ICD-9-CM gives way to ICD-10-CM on Oct. 1, 2014, the importance of complete documentation for fracture coding will take a big leap forward. To cite two examples: In ICD-9-CM, there is no provision for specifying laterality (left or right) and healing processes are very broadly classified. For example, there is only one code for a malunion of a fracture (733.81) and only one code for a nonunion (733.82).

In ICD-10-CM, not only do we indicate laterality but we also have the capability to code a disease process known as “stage of healing.” The four distinct fracture healing processes are:

• Routine healing
• Delayed healing
• Nonunion
• Malunion

These features, as well as routine and delayed healing, are built into the seventh-character “extension” of the ICD-10-CM code. Aftercare following fracture treatment is indicated by the extension “D,” and late effects of fractures are indicated by the extension “S.” In ICD-10-CM, closed and open fractures are further broken down into many subdivisions, which are only tabulated in a list in ICD-9-CM.

When mapping fracture codes from ICD-9-CM to ICD-10, it becomes clear that much more information must be documented in medical records and operative reports. For example, a patient suffers a traumatic open fracture to the lower end of the femoral condyle. In ICD-9-CM, this is simply coded as 821.31 Fracture of other and unspecified parts of femur; lower end, open; condyle, femoral. In ICD-10-CM, however, we add the dimensions of:

• Which condyle (unspecified, lateral or medial; fifth character)
• Laterality (right or left thigh or unspecified; sixth character)
• Whether displaced or nondisplaced (also in the sixth character)
• Type of open fracture (using the Gustilo Open Fracture Classification System; seventh character extension)
• Stage of healing (as listed above; also in the seventh character)

A single ICD-9-CM code (821.31) potentially crosswalks to 36 possible ICD-10-CM code choices in the category S72.4- (including three designations of condyle, three designations of laterality, two binary designations of displacement, and two designations of Gustilo groups [Type I/II and Type IIIA/IIIB/IIIC]). The S72.42- and S72.43- subseries follow a similar progression, with the fifth character representing the lateral condyle in S72.42- and the medial condyle in S72.43-. All of these codes map backward from the general equivalence mapping (GEM) files to 821.31.

March 1st, 2013

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J4 MAC Issues Billing Instructions for Denosumab

Beginning Jan. 1, 2012, a new HCPCS Level II code has been assigned to the drug denosumab. Formally C9272 Injection, denosumab, 1 mg, denosumab should now be reported with J0897 (description remains the same).

The drug denosumab has two brand names with two different indications:

Prolia® - indicated to treat osteoporosis in women after menopause.

Xgeva® - indicated for the prevention of skeletal-related events in patients with bone metastases from solid tumors.

When billing Prolia for patients with postmenopausal osteoporosis, TrailBlazer Health Enterprises instructs providers to report ICD-9 diagnosis code 733.01 Senile osteoporosis on the claim. And when billing Xgeva for patients with bone metastases from solid tumors, providers should report ICD-9 code 198.5 Bone and bone marrow on the claim.

TrailBlazer, Medicare administrative contractor for jurisdiction 4 (J4-MAC), further instructs providers to indicate in the comment section of the claim which drug is being administered, Prolia or Xgeva.

Remember: The medical record must clearly demonstrate the patient has been diagnosed as indicated on the claim.

“Utilizing the recommended diagnosis code in situations where medical records do not support the reported diagnosis  is not appropriate,” TrailBlazer warns.

December 30th, 2011

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Osteoporosis Screening Recommendation Updated

As many as one in two postmenopausal women in the United States is at risk for an osteoporosis-related fracture. Given that, the U.S. Preventive Services Task Force (USPSTF) is now recommending routine screening for osteoporosis in women aged 65 and older, as well as in certain younger women.

Specifically, this recommendation includes women of all racial and ethnic groups 65 and older who do not have a history of an osteoporotic fracture, osteoporosis secondary to another condition, or other specific indication for bone measurement testing, as well as younger women who are at equal or greater risk for osteoporosis than the average 65-year-old women who has no additional risk factors.

Osteoporosis is a condition that occurs when bone tissue thins or develops small holes, which can cause pain, broken bones and loss of body height.

The USPSTF suggests primary care practices offer or provide routine bone density screening to high risk groups, but notes there is a lack of evidence about how often screening should be repeated.

The most commonly used screening test is dual-energy X-ray absorptiometry (DXA) of the hips, pelvis and lumber spine (CPT® 77080). Other screening tests include single energy X-ray absorptiometry (SEXA) (HCPCS Level II G0130) and computed tomography (CPT® codes 77078-77079).

Medicare currently covers bone density screening once every 24 months (more often if medically necessary). Medical record documentation maintained by the treating physician must clearly indicate the medical necessity for ordering bone mass measurements. For dates of service on or after Jan. 1, 2011, there is no copay or coinsurance for bone density screening, pursuant to the Patient Protection and Affordable Care Act of 2010.

Intervention for osteoporosis includes adequate calcium and vitamin D intake and weight-bearing exercise. Treatment to reduce fracture risk in women with low bone mineral density and no previous fractures includes multiple U.S. Food and Drug Administration–approved therapies, such as bisphosphonates, parathyroid hormone, raloxifene, and estrogen.

The USPSTF recommendation summary was first published in the Annals of Internal Medicine, Jan. 18, 2011. A summary of evidence, the full recommendation statement, and supporting documents are available on the USPSTF website.

January 28th, 2011

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Men at Risk for Osteoporosis

Although osteoporosis (low bone mass density or BMD) is considered primarily a problem for older women, a 60-year-old white man has a 25 percent lifetime risk of suffering a bone fracture due to osteoporosis, reports the Agency for Healthcare Research and Quality (AHRQ). Osteoporosis is typically without symptoms and is substantially under-diagnosed and undertreated among men in the United States. A new study reveals certain risk factors for osteoporosis among asymptomatic men can be used to identify those who should be screened for the problem. (more…)

October 13th, 2008

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