Pediatric Coding Alert

Coding for school, sports, or camp physicals presents several problems for pediatricians. First of all, most managed care plans limit the amount of preventive care services codes (99391 - 99395) that can be reimbursed within a certain time period. Therefore, if a child has had a physical within the past year, for example, you may not get reimbursed for doing another one. We have received many questions from readers about how to get reimbursed for these exams. Like many coding questions, this one has more than one answer.

1. Preventive-services codes. I think the safest way is to use a preventive-care code, says Debbie Abbott, billing supervisor for Pediatric Associates, a seven-pediatrician practice in Newark, DE. If it takes place as a regularly scheduled physical, we will just fill out the additional paperwork for the school or camp physical, she says.

Abbott calls the preventive services codes safe because of the diagnosis-code problem. What kind of diagnosis code would you use for a visit which is essentially a well-visit? We use V20.2 for sports physicals, says Abbottthe same diagnosis code you would use for a well-visit.

Lynn Bloom, insurance administrator for Maple Avenue Pediatrics, a four-pediatrician practice in Fair Lawn, NJ, has a slightly different attitude about sports physicals. She does use the preventive-care codes, but she doesnt bring the child in for another physical, as long as he or she has had one within the past year. We have enough trouble fitting in our patients for physicals, says Bloom. So if theyve had a physical within the past year, the nurse will just fill out the form. No, there is no way of getting reimbursed for this nurses time, says Bloom. But its better than trying to jam unnecessary appointments into the already overcrowded schedule.

Tip: This may be risky for some practices. Often, schools require a sports physical to be a current exam because of their possible liability if the child is injured or has a health complication that would make participation dangerous. If the child later has complications, and it is determined that the practice filled out the paperwork without performing an exam, the pediatrician could be liable.

2. Use consultation codes. Theoretically, you can use the consultation codes (99241-99245) if the request for the physicians opinion comes from a doctor affiliated with the school or from the school nurse. And, of course, these codes are attractive because they reimburse so well. However, you must have a referral from a physician affiliated with the school, if you want to collect from Medicaid. And while some private insurance companies will accept a referral from the school nurse, some have the stricter standard.

CPT states that a consultation must be requested by another physician or other appropriate source.

Tip: If you use consult codes, make sure you document the request for a medical opinion in the childs record. And be sure to document who requested the opinion.

Also, you cannot use the V20.2 diagnosis code. Instead, you should use V70.3, which is for other medical examination for administrative purposes, including camp, school admission, and sports competition.

However, in reality, using the consultation codes may very likely yield no reimbursement at all. We have not found any practices who are successfully using the consultation codes for sports physicals. As Abbott says, it is much safer to use the preventive-services codes.

Note: The objective here should not be trying to sneak around the insurance rules to gain coverage. If the sports physical is not covered, then the parent should pay for it. One practice does it this way: All sports physicals require payment in advance from the parent. The practice submits the claim to the insurance company, and refunds the money to the parent if the insurance covers the exam.

3. Contract with school district. One solution is to contract with the school district to do these physicals, bypassing the insurance companiesand the codesaltogether. This is what the Cooper Health System in Camden, NJ, does. Tina Cressman, CPC, reimbursement analyst for the 45 pediatricians in the system, explains that the school district puts the contract out for bids. We agree to see a certain number of children for a set fee, the biller says.