Medicare Compliance & Reimbursement

Note: Sports physicals don’t necessarily include counseling and anticipatory guidance components.

Uncertain how to code for a sports exam to ensure reimbursement? Consider these scenarios before submitting your next claim.

Check if You Can Report a Regular E/M Code for Sports Physicals

There is no exact matching CPT® code to report a sports physical. You might be tempted to report a preventive medicine code such as 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 appropriate immunization[s], laboratory/diagnostic procedures, new patient ...) for new patients or 99393-99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual ...) for established patients. However, sports physicals by themselves do not always rise to this level of service.

“For instance, sports physicals do not always necessitate the kind of comprehensive, age and gender appropriate history and examination associated with preventive medicine visits,” points out Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. Likewise, sport physicals do not necessarily include the counseling and anticipatory guidance components of a regular well-care visit.

“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),” Moore observes. You will have to use an appropriate diagnosis code such as V70.3 (Other general medical examination for administrative purposes).

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 physicals do not involve a chief complaint or medical diagnosis, some payers may consider it inappropriate to report one with 99201-99215. So, you will have to check with the payer to see if you will be able to report a regular E/M code for a sports physical.

Understand When to Report a Preventive Medicine Code

Another option is to schedule patients for their regular annual physical and incorporate the sports physical in that visit. 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.

Depending on the age of the patient, you can look at the appropriate code from 99383-99385 for new patients or report from 99393-99395 for established patients. You also have two choices for the preventive examination’s diagnosis. Select V20.2 (Routine infant or child health check) 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).

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.

“You may be able to bill the patient for completing the paperwork independent of a visit; it will probably depend on the terms of your contract with the patient’s insurer. If your contract does allow you to bill patients directly for this administrative service, be sure that your patients are aware of that and the associated charges in advance,” Moore adds.

Warning: For liability reasons, your physician may not want to issue a form without checking the patient to see if his status has changed.

Example: An established 16-year-old male patient requires a sports physical to play school soccer. Since he has not had his annual physical in the past one year, you schedule an annual physical instead of just a sport physical.

What to report: Since the patient had a full-fledged annual physical, you report 99394 (Periodic comprehensive preventive medicine reevaluation and management ... established patient; adolescent [age 12 through 17 years]) for this service. Assign the routine general medical examination code V20.2 to inform the payer that your physician performed all the components of a regular well-care visit.

Look Towards Charging the Patient as Last Option

If the patient has had a regular well-care visit already and the payer will not allow you to report an E/M code for a sports physical, you may have to look at charging the patient for the visit, since most payers only cover one well-care visit per year. You should inform the parents that a sports physical is not a covered service and the payer may not pay for the service. Then, you can charge the parent up front when your physician fills out school paperwork and/or performs a non-covered physical exam.

Best bet: When in doubt, have the patient pay up front and submit the claim to the insurance. If you receive reimbursement for the claim, you can then pay the patient back.