Certified Risk Adjustment Coder (CRC)

Which diagnosis would you predict if a member had a DME claim for a cane and an Rx Claim for Fosamax?

1. Osteoarthritis

2. Degenerative joint disease of the knee

3. Spinal Stenosis

4. Osteoporosis

The correct answer is: Osteoporosis

The presence of a Durable Medical Equipment (DME) claim for a cane strongly indicates a need for support in mobility, which can be associated with conditions that affect strength and balance. Additionally, the prescription claim for Fosamax, a medication primarily used to treat osteoporosis, further supports the diagnosis. Fosamax effectively helps to strengthen bones and reduce the risk of fractures in individuals diagnosed with osteoporosis. Osteoporosis is a condition characterized by decreased bone density, increasing the likelihood of fractures and complications. This condition often leads to mobility issues, making the use of a cane necessary for support and safety. The combination of these two claims—the cane for mobility assistance and Fosamax for the management of osteoporosis—points clearly towards a diagnosis of osteoporosis. The other conditions listed, while associated with joint and mobility issues, do not specifically align with the use of Fosamax. Osteoarthritis and degenerative joint disease may lead to the need for assistive devices, but they are not treated with Fosamax. Spinal stenosis may also cause mobility issues and discomfort but is unrelated to the use of Fosamax. Thus, the combination of a cane and Fosamax confidently indicates a diagnosis of osteoporosis.