Pediatric Coding Alert

Now that school has begun, pediatricians will be performing sports exams, which are generally required for sports in middle, junior and high schools. The school wants to avoid liability by obtaining medical clearance but doesnt pay the pediatrician to provide a clean bill of health. The childs health insurance may pay for the service, however, depending on how the claim is coded. The dilemma for pediatricians is that although there is a diagnosis code for sports physicals (V70.3, other examination for administrative purposes), there is no CPT code. Depending on the situation, there are several methods to increase chances that insurance will cover the visit.

Concurrent Preventive Medicine Exams

 Incorporate the sports physical into a prescheduled preventive medicine exam. Although this will not warrant additional payment, the visit will at least be paid. Report 99383-99385 (initial preventive medicine evaluation and management of an individual new patient) or 99393-99395 ( established patient), depending on the patients status and age.
 
For example, an 11-year-old boy requires medical clearance to play varsity soccer. When the mother calls to make an appointment, the scheduler notices that the boy is due for a preventive medicine service and books a full well visit. The doctor performs the physical and completes the sports form. Code the visit 99393 (... late childhood [age 5 through 11 years]), using the well-visit diagnosis (V20.2 , routine infant or child health check).

Extra Preventive Medicine Exam

Because of the work involved in a sports exam, in some cases pediatricians may bill a preventive medicine visit even if the child is not due for a checkup.
 
For example, a 14-year-old girl plans to play basketball. The pediatrician saw the girl for a full well visit 10 months ago but feels that the information from that encounter is current enough to qualify for the sports physical. He or she performs the requirements of the sports physical -- a superficial complete exam with emphasis on the musculoskeletal system -- and codes 99394 (... adolescent [age 12 through 17 year]).
 
Many insurers will cover only one well visit per year. If the child has already had a well visit within 12 months, payment for the sports exam may be rejected.

Recent Preventive Medicine Exam

This scenario entails copying the information from the chart of a recent well visit onto the sports physical form. If the well visit occurred recently (i.e., within one calendar year) and there are no ongoing medical problems, most pediatricians would feel comfortable doing this, says Richard H. Tuck, MD, FAAP, founding chairman of the AAP coding and reimbursement committee and a practicing pediatrician in Zanesville, Ohio. This service would not warrant an extra fee, although there would be the extra office work of pulling the chart and completing the form.
 
For example, a 9-year-old girl wants to be on the swim team. She underwent a well visit just a month ago. To clear her medically for the sports activity, the pediatrician simply transcribes the information -- including height, weight, blood pressure and heart rate -- from the chart to complete the sports physical form.

Consultations

 Reporting a consultation code (99241-99245, office consultation for a new or established patient) for a school-required sports physical is appropriate but would require a request for a consultation from the school nurse or athletic coach. The request, which could be via telephone or in writing, must be documented in the childs record. Link diagnosis code V70.3 to the consultation. If the child has an ongoing medical condition, use the diagnosis for that condition in place of the V code.
 
Note: When coding consultations, remember the Three Rs --  request (for your opinion), reason for the visit (documented) and report (back to the requester).
 
The most applicable scenario for a consultation is a child with an ongoing condition who wants to participate in athletics. For example, a child with controlled asthma wants to play softball. The school nurse asks, in writing or by telephone, for the pediatricians opinion and advice.

The pediatrician conducts the consultation, including a full history, exam and medical decision-making, and sends his or her recommendations to the nurse. Bill the appropriate consultation code with the asthma diagnosis code, 493.xx.
 
In another example, a 13-year-old boy suffered a fractured tibia playing soccer the previous year, yet is anxious to play again. The school nurse and the coach both want clearance from the pediatrician. Report the appropriate consultation, with the fractured-tibia diagnosis, 823.80.
 
Even though its now healed, the fractured tibia is the reason the child is being brought in, Tuck says.
 
Alternatively, if the child is having symptoms, such as back pain (724.x), code the symptoms.
 
For a healthy child, billing consultations for sports physicals presents one big problem: the diagnosis. The most appropriate diagnosis is V20.2 for a preventive medicine visit or V70.3 for sports medicine. If you link either diagnosis to a consultation code, the insurance companys computer will reject the claim. If there is no physical condition that prompts the need for a sports clearance, the visit likely will not be paid.

Modifier -52 
 
Another option is to bill a preventive medicine services visit (99393-99395) with modifier -52 (reduced services). Use this modifier if you are providing a partial, rather than complete, preventive medicine service, says Jillian Phillips, CPC, CCS-P, coding consultant for the Ohio State Medical Association in Hilliard, Ohio.
 
Usually, the pediatrician doesnt do a comprehensive history and exam for a sports physical, Phillips says. But what they do is more similar to a preventive exam than a sick visit, and modifier -52 reflects that less than the full service was performed. Link the diagnosis code for sports physicals (V70.3) to the preventive medicine service.
 
Again, this presents a problem with insurance companies that will pay for only one well visit a year. Although this is correct billing, you may have to appeal.

Special Reports Code

Pediatricians could bill for an office visit or a consultation for the physical, and 99080 (special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form) for filling out the form. Code 99080 is appropriate for filling out extensive reports (e.g., life insurance forms), although insurers will not always reimburse for it. Sports clearances are generally simple, however, and their completion is generally considered part of the postencounter work. If the nurse completes the form, it must be reviewed and signed by the physician.
 
Check Your Contracts

 Sports physicals constitute an individual plan benefit design issue. Before billing the parents, check your contract to make sure this is allowed. If the plan does not cover sports physicals, it is appropriate to bill the parents.
 
Some physicians choose to write off the sports physical, especially if it is cursory -- although Tuck strongly discourages this because it involves physician work and should be reimbursed.