DXA Structured Report Builder

Clinical Data Entry

Routine report — fill top to bottom — BMD/DXA · image quality · Rx decision · follow-up

Clinical Decision Support — Quick Reference · ISCD 2019/2023 · BHOF 2022 · AACE/ACE 2020 · reference only — nothing here enters the signed report

VFA — when to obtain (ISCD 2019)

Obtain when the lowest T-score ≤ −1.0 AND ≥1 qualifier present: woman ≥70 / man ≥80; historical height loss >4 cm (>1.5 in); self-reported undocumented prior vertebral fracture; glucocorticoid ≥5 mg/d prednisone-equiv for ≥3 mo.

A confirmed Genant Grade 2–3 (>25% height loss) vertebral fracture is a clinical osteoporosis event independent of BMD/FRAX. Grade 1 (20–25%) is not ISCD-reportable.

TBS — when to obtain

Adjunct that refines FRAX — not a standalone or diagnostic test. Consider when FRAX-major is borderline near the intervention threshold OP, in T2DM (BMD underestimates risk), or with unexplained spine–hip discordance.

Validity: age ≥40, BMI 15–37, no severe L1–L4 artifact. iNsight bands (Hologic/Medimaps): ≥1.350 normal · 1.200–1.350 partially degraded · <1.200 degraded. Apply TBS-adjusted FRAX only when all validity criteria are met.

Pharmacologic therapy — when to treat

Initiate (BHOF 2022 / AACE-ACE 2020) when any: hip or vertebral fragility fracture (any BMD); T ≤ −2.5 (spine, FN, TH, or 33% radius); T −1.0 to −2.4 + FRAX hip ≥3% or major ≥20%; glucocorticoid-induced per ACR 2022.

High risk → antiresorptive first-line: alendronate / risedronate PO · zoledronic acid IV · denosumab SC. Denosumab has no holiday — transition to a bisphosphonate within 6 months of the last dose to prevent rebound vertebral fracture.

Very-high risk → anabolic-first

Anabolic-first preferred if any: T ≤ −3.0; recent fragility fracture (e.g. <12 mo); fracture while on therapy; multiple fragility fractures; fracture on bone-toxic drugs; very high FRAX (hip >4.5% / major >30%); high risk of injurious falls.

Agents: teriparatide (≤24 mo) · abaloparatide (≤18 mo) · romosozumab ×12 mo (dual-action anabolic + antiresorptive; avoid with recent MI/stroke). Follow with an antiresorptive to preserve gains.

Secondary-cause screen — when & what

Screen when: osteoporosis without an obvious risk factor; premenopausal woman / man any age with low BMD or fragility fracture; Z ≤ −2.0; unexplained fracture or loss > LSC on therapy; unexplained spine–hip discordance; inadequate response after 1–2 y of adherent therapy.

Tier 1: CBC · CMP (Ca / phosphate / renal / hepatic) · 25-OH D · intact PTH · TSH · 24-h urine Ca · celiac (tTG-IgA + total IgA) · total testosterone (men).

Tier 2 (directed): SPEP/UPEP + free light chains · CTX / P1NP · AM cortisol or 1 mg dexamethasone suppression · ferritin/iron · tryptase · LH/FSH/estradiol · B12 / zinc / magnesium.

Site validity & side-to-side discordance

Exclude a hip or site when: hardware / arthroplasty / fixation in the ROI; overlying contrast or external radiopaque object; focal lesion / fracture / Paget in the ROI; excess rotation / malposition or motion; marked degenerative sclerosis (elevates BMD). One hip invalid → use the contralateral hip; neither valid → spine and/or 33% radius. Diagnostic hip ROIs = total hip + femoral neck only (not Ward's / trochanter).

Left vs right (or forearm): classify on the lower side — do not average for diagnosis (mean hip for monitoring only). Significant when it exceeds the site LSC, reclassifies the category, or crosses a treatment threshold. Forearm = non-dominant 33% radius, diagnosis-only (ISCD does not validate it for serial monitoring).

OP operational threshold — practice-pattern default, not a graded guideline recommendation. FRAX intervention thresholds (hip ≥3% / major ≥20%) and AACE/ACE risk categories are validated for postmenopausal women and men ≥50; for premenopausal women and patients <50, use Z-score and evaluate secondary causes. Reference only — nothing in this panel is added to the signed report.

1. Study Metadata

Exam date

Report date

Referring clinician

Indication for study

If "Other": specify

Reason-for-study phrasing (report boilerplate)

Insurance-approved indication (Medicare NCD 150.3 — documents medical necessity)

Densitometer / location

Electronic signature date/time (blank = auto-fill current Central Time)

2. Demographics

Patient name

Patient ID / MRN

Date of birth

Age

Sex

Menopausal status (F)

Age at menopause

Ethnicity (FRAX)

Height (in)

Weight (lb)

BMI (kg/m²) — auto

3. BMD & T-Scores (postmenopausal F / men ≥50)

Site

BMD (g/cm²)

T-score

Z-score

Femoral neck right

Total hip right

Femoral neck left

Total hip left

Lumbar spine L1–L4

33% radius forearm

ISCD: diagnosis uses the lowest T-score among L1–L4, femoral neck, total hip, or 33% radius. Ward's area and greater trochanter are excluded. Vertebral exclusion and lumbar-spine validity are set in the Scan Technical / Site Validity section below.

4. FRAX

10-yr Major OP fracture (%)

10-yr Hip fracture (%)

TBS-adjusted

GC-adjusted

Calculated on/after therapy

FRAX should be reported for all osteopenia T-scores (−1.0 to −2.4). GC-adjustment required if dose >7.5 mg/d prednisone-equivalent.

5. Fracture History & Therapy

Any prior fragility fracture (≥50)

Fragility Fx within 12 months

≥2 fragility fractures

Hip or clinical vertebral Fx

Currently on OP therapy

Fracture while on therapy

On drug holiday

High adherence to therapy

A clinical Grade 2–3 vertebral fracture on VFA = osteoporosis by clinical definition; counts toward "fragility fracture" above.

6. Scan Technical / Site Validity

Spine OK for diagnosis?

Hip rotation a problem?

Spine confounders — tick any present (these pull the artifact caveat into the report):

Focal degenerative change / osteophytes / endplate sclerosis

Extensive multilevel degenerative disease

Significant scoliosis

Vertebral fracture / deformity

Artifact (hardware / cement / contrast / calcification)

Prior laminectomy / fusion

T-score >1.0 above an adjacent vertebra (ISCD discordance criterion)

Non-assessable / poor visualization

Detail & site validity — add as needed

Lumbar spine evaluability & vertebral exclusion

Lumbar spine interpretable for diagnosis?

Individual vertebrae excluded from the L1–L4 average (leave ≥2 for a valid spine)

Additional technical note (optional free text)

ISCD criteria: a valid lumbar-spine diagnosis needs ≥2 evaluable vertebrae (L1–L4). Exclude any vertebra that is non-assessable, focally affected, or whose T-score is >1.0 above an adjacent level. Extensive degenerative disease artifactually elevates spine BMD — if non-diagnostic, set “No — non-diagnostic,” leave spine BMD blank, and base the diagnosis on the hip. Checked reasons pull directly into the report; excluding the affected vertebra removes the artifact caveat for the remaining spine.

Hip / femur acquisition & positioning

Femur rotation present? (lesser trochanter prominent)

Does rotation interfere with interpretation?

Right and left hip BMD not reported

Total hip BMD not reported

Femoral neck box placement not optimized

Left/right side discordance comment — pull into report

Hip / femur non-BMD findings (study assumed valid unless flagged)

Affected side

Degenerative change / sclerosis (osteoarthritis) — may elevate BMD

Arthroplasty / fixation hardware / deformity — side not valid for classification

Focal lesion overlapping the measurement ROI

AFF spectrum: focal lateral cortical thickening ± lucent line

Rotation / external object / motion artifact

Hip findings note (optional free text)

Opt-in: the report assumes the femur study is valid for interpretation; check items only when present. Hardware and ROI-overlapping lesions invalidate that side for classification (diagnose from the contralateral hip, spine, or 1/3 radius); AFF-spectrum change prompts dedicated femur radiographs, especially on long-term antiresorptive therapy.

Forearm / distal 1/3 radius

Forearm DXA indication (when forearm performed)

Forearm — other indication (if "Other" selected)

7. Treatment Decision

Diagnosis (overrides T-score auto-classification)

Treatment direction

Treatment & follow-up decision support (reference — pull your choice in via the dropdowns)

Very-high-risk → anabolic-first: teriparatide 20 mcg SC daily (≤24 mo) · abaloparatide 80 mcg SC daily (≤18 mo) · romosozumab 210 mg SC monthly ×12 (women; avoid in established CVD). Follow with an antiresorptive to preserve gains; endocrine referral reasonable.

High-risk → antiresorptive:

Oral bisphosphonate (alendronate 70 mg weekly · risedronate 35 mg weekly): first-line; verify Ca / vit D ≥30, dosing technique, GI & dental status.
IV bisphosphonate (zoledronic acid 5 mg yearly): for GI intolerance / adherence concerns; eGFR ≥35, vit D ≥30, dental status; counsel acute-phase reaction.
Denosumab 60 mg SC q6 months: verify Ca / vit D, no hypocalcemia. ⚠ Never lapse >7 months — discontinuation requires bisphosphonate transition to prevent rebound vertebral fracture.

Other: raloxifene 60 mg daily (postmenopausal, ↑breast-Ca risk, no VTE; spine benefit only) · MHT (prevention only — symptomatic women <60 or within 10 y of menopause, NAMS 2022).

Drug-holiday criteria: after 3–5 y oral BP or 3 annual ZA infusions, in stable BMD without high-risk features. Not applicable to denosumab. Resume if new fragility fracture, BMD loss ≥ LSC, or T ≤ −2.5.

Follow-up interval: on therapy 1–2 y to assess response · rapid-loss (GC / aromatase inhibitor / ADT / post-bariatric) 1 y · stable / screening 2 y (Medicare minimum) · low risk 2–5 y.

Additional treatment nuance (free text — appended after the default recommendation)

Secondary cause workup

Targeted workup statement (used when "Targeted" selected)

Atypical femoral fracture (AFF) assessment

Care team referrals (select all that apply)

Physical therapy — strength, balance, falls assessment

Progressive strength-training program (community or supervised)

Registered dietitian — protein, calcium, vitamin D optimization

Bone health / wellness coach — adherence & behavior change

Endocrinology / metabolic bone specialist

Fall-prevention measures (home safety, balance, med/vision review)

Include True Health team-based program statement (default)

Each dropdown defaults to "Auto" which uses derived logic. Override any to use stable boilerplate for that section. CPT/ICD-10 coding and the audit follow the diagnosis selection.

8. Follow-up

Bone turnover markers (BTM) — optional, pull in as indicated

Follow-up DXA interval

▼ Situational — enter only as needed — risk factors, Z-score, adjunctive, prior comparison, secondary workup

9. Risk Factors & Modifiers

10. Z-Score (age <50 or premenopausal)

Lowest Z-score

For age <50 or premenopausal women: WHO T-score categories do NOT apply. Z-score ≤ −2.0 = "below expected range for age."

11. Adjunctive Studies

TBS (L1–L4)

ISCD TBS indications: age ≥40, BMI 15–37 kg/m², no severe L1–L4 artifact. Hologic/Medimaps iNsight: normal >1.350; partially degraded 1.200–1.350; degraded <1.200.

VFA findings

VF level(s) — if applicable

Grade 1 VFs (20–25% height loss) are NOT reportable per ISCD. Any Grade 2–3 VF escalates fracture risk independent of BMD and FRAX.

12. Prior Comparison

Prior studies reviewed

Comparison status

Prior study date

Add comment: obtain prior DXA studies for comparison, if available (standing boilerplate)

Same device + software

Same technologist

Mean total hip BMD change vs prior (%)

LSC significance interpretation

Facility LSC — total hip (%)

Facility LSC — lumbar spine (%)

LSC source

Serial comparison should use mean total hip (not femoral neck) per ISCD. Lumbar spine LSC applies when spine is the monitoring site of reference. Change is significant only if ≥ facility LSC (95% CI). Per ISCD, valid serial comparison requires the same densitometer (device + software) and ideally the same technologist, or formal cross-calibration when these change.

13. Secondary Workup Status

Secondary cause workup already completed and reviewed

ISCD-Compliant DXA Report

Default boilerplate Supplemented by your selection