Orthopedic Coding Alert

Assessing an athlete's fitness level? Ask for payment up-front

Autumn means that many sports-medicine practices will bid farewell to skateboarding, tennis and softball injuries and instead usher in the swarms of fall-sports athletes in need of their preseason physicals.
 
The biggest mistake offices make when reporting these sports exams is using the 99201-99215 series. Don't make the same mistake: Stay on the ethical path by asking for payment at the time of the exam.
 
Vary Exam Components by Circumstances

Sports exams focus on the patient's fitness for a designated sport. The extent of the history, examination, medical decision-making and counseling depends on the child and the reasons you're performing the exam, says Victoria S. Jackson, administrator at Southern Orange County Pediatric Association in Lake Forest, Calif.

Youth sports may require you to perform a lower-level service than high-school sports. "For instance, sports exam for Pop Warner sports, such as Little League Softball, are very simple," Jackson says. A high-school sports exam may be more extensive.

Sports Exams Aren't 'Problem-Focused'

Although CPT doesn't include specific codes for sports exams, one thing is clear: The standard E/M series codes (99201-99215 for outpatient visits) don't apply. These codes describe "problem-focused" exams. In other words, the patient must be presenting for an injury or illness. Read on for tips on how to hold on to your sports exam income.

1. Collect Payment Up-Front. You should inform parents that sports physicals, unlike annual preventive medicine visits, are usually not covered by insurance. And, because children and young adults will get their physicals at their pediatrician's or family practitioner's offices, it's unlikely that your orthopedic surgeon will perform a complete annual visit that would warrant reporting a preventive medicine code (99382-99385 and 99392-99395).

Solution: You should charge the parent cash up-front for the service. "Most parents are happy to pay the $15 that we charge for the physician's child evaluation and form completion," says Tammy Trench, CPC, accounts receivable technical adviser at Apex Practice Management in Oklahoma City. 

2. You'll Usually Avoid Preventive Medicine Exam Codes. Some coders defend their decision to submit a preventive medicine code for sports physicals by referencing the August 1997 CPT Assistant, which states that the physician should report a preventive medicine code for a sports exam "If the physician performs a comprehensive history and examination."

However, to charge a code from the 99382 or 99392 series, the physician must cover 10 of the 14 areas in his review of systems (ROS).
 
Because it is rare for an orthopedic surgeon to perform a comprehensive ROS during a sports exam, you should not report a preventive medicine code in most cases.

In the rare situations when you do think you have enough documentation to report a preventive medicine exam, you should link the code to V70.3 (Other medical examination for administrative purposes).

3. Reject Alternative Methods. Even if your physician's documentation meets the criteria to report the preventive medicine codes, some insurers may still reject your claim because they don't accept V70.3 as a diagnosis code with the 99382 or 99392 series.  

Blue Cross Blue Shield sometimes inquires about the reason for a well exam, Trench says. "But when the representative finds out the visit is for a sports exam, the insurer won't cover the service."

Do not attempt to get around V70.3 noncoverage by reporting 99383-99385-52 or 99393-99395-52 (Reduced services) with V70.0 (Routine general medical examination at a healthcare facility).

Not only will assigning the well-visit diagnosis use up the child's annual checkup, but CPT admonishes against this alternative billing method. "It would not be appropriate to append modifier 52 to a preventive medicine E/M service code when only a brief history and examination is performed," states CPT Information Services, dated April 13, 2001.