EM Coding Alert

Consider collecting from the patient when you can’t bill the payer.

Summer and early fall are peak times for practices to receive calls from patients about getting physicals for camp, sports, or school, but if you don’t know how to code for these visits, you could cost your practice hundreds per encounter.

Learn when you can — and can’t — report an E/M code for these types of physical encounters to ensure you aren’t leaving money on the table.

Review the E/M Options First

CPT^® does not offer a specific code to report a sports, camp, or school physical. Whether you can report another type of E/M code for the encounter, depends on your provider’s documentation and the timing of the physical.

Option: Many practices ask patients to schedule their normal annual physical at a time when they can use the visit to fulfill sports/camp/school requirements. If the patient has not had a full preventive service in the last 12 months, you can inform the parent when he calls for an appointment that the physician will perform the full preventive service and you’ll bill to the insurance. Then you can fill in the school, sports, or camp physical form in conjunction with the preventive visit.

“If the child is due for a normal well child check, we will typically perform that service and just fill out the camp/sports/school physical at that time,” says Charlene Endre-Burgett, MS, CMA (AAMA), CPC, CMCS, CHM, CPOM, administrator for North Scottsdale Family Medicine in Arizona.

Depending on the age of the patient, you can look for the appropriate code from 99383-99385 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient...) for new patients or report from 99393-99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual...) for established patients.

Dx help: You also have two choices for the preventive examination’s diagnosis. Select V20.2 (Routine infant or child health check, [ICD-10: Z00.129, Encounter for routine child health examination without abnormal findings or Z00.121, ... with abnormal findings]) for children up to age 18. For those who are age 18 or older, shift to V70.0 (Routine general medical examination at a health care facility, [ICD-10: Z00.00, Encounter for general adult medical examination without abnormal findings or Z00.01, ... with abnormal findings]). Plus, if you are in a gynecology office, you could use V72.31 (Routine gynecological examination, [ICD-10: Z01.411, Encounter for gynecological examination {general} {routine} with abnormal findings, or Z01.419, ... without abnormal findings]) for the general gynecological examination.

Alternative: You may also use information from a recent preventive medicine service exam to fill out a patient’s school, sports, or camp form, but you probably can’t bill a separate service to the insurer for this. But be careful — for liability reasons, your physician may not want to issue a form without checking the patient to see if his status has changed.

Ensure Documentation Supports the Coding

You might be tempted to report a preventive medicine code for all sports/camp/school physicals but physicals by themselves do not always rise to the level of service required for 99383-99385 or 99393-99395. To complete a physical that lets your physician give a college student clearance to play football, he may not, necessarily, capture the “age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions” or some other element of the requirements for these codes to support a preventive medicine E/M code. The documentation is always your guide to which service you should report.

“Sports physicals have very little criteria associated with them where a ‘routine well visit (99383-993855 and 99393-99395) has specific criteria associated with it, such as chronic issues have to be addressed during a well care visit but a sports/camp physical does not have that attached to it,” says Donelle Holle, RN, a healthcare, coding, and reimbursement consultant in Fort Wayne, Ind. “If a provider is going to do the actual well care codes then they have to justify the code based on its criteria.”

Accordingly, the American Medical Association (AMA) advises that if the physician performs a brief, detailed, or extended history and examination, then you should report the appropriate level office or other outpatient evaluation and management visit code (99201-99215). You will have to use an appropriate diagnosis code such as V70.3 (Other general medical examination for administrative purposes).

Caution: If your physician uncovers a problem during the visit, a diagnosis reflecting that problem should be reported, which will especially support the visit. Because 99201-99215 are problem-oriented codes and V70.3 is not a problem-oriented diagnosis, some payers do not consider V70.3 a covered diagnosis.

Likewise, because sports/camp/school physicals do not involve a chief complaint or medical diagnosis, some payers may consider it inappropriate to report one with 99201-99215. Since you won’t have a chief complaint or medical diagnosis, submitting these codes could be considered fraud without the appropriate documentation supporting such a service. So, you will have to check with the payer to see if you are able to report a regular E/M code for a sports/camp/school physical.

Pointer: Remember that if the physician does not have documentation of a full comprehensive history and age-appropriate comprehensive examination, you can report unlisted-procedure code 99499 (Unlisted evaluation and management service). Check with your payer to see if this is something you can bill for sport/camp/school physicals.

Pitfalls: You should also pay attention to the following important tips for what not to do when billing sports/camp/school physicals:

Do not submit a preventive code with modifier 52 (Reduced services).

Do not report 97005 (Athletic training evaluation) or 97006 (Athletic training re-evaluation) because these codes represent problem-oriented services, such as a sports injury.

No Code? Charge the Patient

When a patient comes in for a sports/camp/school physical that you can’t code a preventive visit for and his insurance company won’t cover, you can collect from the patient directly. Treat the encounter as a self-pay service and collect at the time of service. Posting your fees for such encounters is important from a customer service prospective.

First step: Inform parents that, unlike annual preventive medicine services, sports/camp/school physicals are usually non-covered services and their payer may not pay for the service, Burgett says. Then, you can charge the parent or guardian up front when your physician fills out school or camp paperwork and/or performs a non-covered physical exam.