Medicare Compliance & Reimbursement

Question: We had an asthmatic patient present because she required an Epi-pen to take to camp with her. We gave her a full camp exam and prescribed an Epi-pen for her peanut allergy, as well as Proventil to take with her. Should we report this as a problem-focused visit or as a camp visit? Our pediatrician initially billed 99211 with V15.01 (Personal history of allergy to peanuts) but the insurer rejected it.

Answer: This visit could actually go either way. If you choose to report a problem-focused visit, you’ll probably report 99212 (or another code from the 99211-99215 series, depending on the documentation). If the pediatrician evaluates the asthma during the visit, you can use that as your diagnosis code (for instance, 493.9), as long as it’s documented in the chart that he addressed it and explained how to use the Proventil with the patient. In addition, you can use V15.01 as another diagnosis to show that you discussed the peanut allergy and how to use the Epi-pen.

However, if the doctor didn’t address any problems and only did the camp physical, you’ll report the visit that way. If you fill out a camp or sports form at the time of an E/M service, such as a preventive medicine service, you won’t code anything additional for the form. That’s because the form’s completion is typically considered included in the E/M service (for instance, 99394, Periodic comprehensive preventive medicine reevaluation and management of an individual ... adolescent [age 12 through 17 years]).

If you’ve already given the prospective camper her preventive medicine service for that year, you may be able to report a preventive medicine visit but chances are high that the insurer won’t pay you for it. CPT® Assistant advises that if the physician performs a comprehensive history and examination, you should report the age appropriate code from the Preventive Medicine series (e.g., 99394). If the physician performs a brief, detailed, or extended history and examination, then CPT® Assistant advises that you report the appropriate level office or other outpatient evaluation and management visit code (e.g., 99212). In this case, you should inform parents that sports and camp physicals are often noncovered services and that you may charge them up-front for the service.

Note: There is an ICD-9 code for a camp exam (V70.3, Other general medical examination for administrative purposes) and a comparable code in ICD-10 (Z02.89, Encounter for other administrative examinations).