EM Coding Alert

Question: I work at a family practice that performs a lot of physicals for kids — for school, sports programs, etc. What is the best code to choose when a patient reports to the practice for a school or sports physical?

Oregon Subscriber

Answer: The E/M code you’ll choose will depend on the encounter type, the patient’s status with the practice and, in some cases, particular payer rules.

CPT^® 2016 doesn’t include codes to report a physical specifically for school or sports. In some cases, you can use an E/M code for these encounters. These aren’t always codeable services, however. If the provider is just filling out a form, or performing another physical in the same calendar year, you shouldn’t report the service.

If the patient has not had a full preventive service within the last 12 months at the practice, the provider can combine the school/sports physical with the annual well check. The physician performs the full preventive service, and then fills in the school/sports form based on the results of the preventive service.

The appropriate code for these preventive visits depends on patient status and level of encounter. You’ll choose 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 and
• 99393-99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual...) for established patients.

Since the code descriptors for 99383-99385 and 99393-99395 often bear little resemblance to what actually occurs during a school/sports exam, you might not be able to choose these codes for your provider’s services. If a provider is going use these codes, then he must satisfy the criteria for the code during the encounter.

Do this: Go back and check the notes on any school/sports physical service. If the service does not meet the criteria for 99383-99385 or 99393-99395, check for evidence of a medically necessary brief, detailed, or extended history and examination. If you can find these elements in the encounter, then you might choose the appropriate level E/M code instead:

• 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: …) for new patients; and
• 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity) for established patients.

If, however, the visit does not meet the criteria for a preventive medicine visit and the notes do not document a full history and examination, you might report unlisted-procedure code 99499 (Unlisted evaluation and management service). Using this code doesn’t necessarily mean the service is reimbursable. The documentation of the physician will guide the payer, as it will determine whether or not the service meets its reimbursement requirements.