Pediatric Coding Alert

Children need physicals to participate in their favorite sports year round, but the demand can grow with warm weather approaching. Ideally, the need for sports physicals should provide the opportunity to offer complete age-appropriate medical exams following the American Academy of Pediatrician's Bright Futures Guidelines. If your practice runs into reimbursement obstacles for full-scale physicals, however, follow our experts' advice to code correctly and still stay in the game.

Choosing the diagnosis code for a sports physical is fairly easy. You'll use V70.3 (Other medical examination for administrative purposes).

Choosing the best CPT code for a sports physical is a bit trickier. "I struggle with this because the service rendered is preventive, but doesn't meet the criteria (in my opinion) of the preventive medicine E/M codes," says JoAnne M. Wolf, RHIT, CPC, coding manager for Children's Physician Network in Minneapolis, Minn.

Here's why: In most cases, a child coming for a sports physical doesn't have a chief complaint, so it seems inappropriate to code from the 99201-99215 range (codes for an office or other outpatient visit for the evaluation and management of a new or established patient), Wolf points out.

Although the preventive medicine E/M codes 99381-99397 (codes for initial or periodic comprehensive preventive medicine evaluation and management of an individual) satisfy the requirements for sports physicals, they also seem inappropriate. When the patient only requests a sports physical, the service you provide doesn't meet the codes' comprehensive nature.

"Physicals are a very hard topic to discuss because some insurances will not cover them at all and some will cover them in different ways," says Susie Stokes, CMC, CMOM, practice manager of Morgan Pediatric Group in Smyrna, Tenn.

Common guidelines can include:

• One per calendar year

• One per year following the patient's birthday

• One after one year and one day after the last physical.

Other complications can arise because of the sports organizations' rules. For example, Stokes says most school sports in her area require a physical after May 1 of the current year. If the child had a physical before May 1 and the sports league requires it after May 1, the parents have a dilemma: They don't want to pay for another physical and the insurance provider will not pay.

"In this case we go ahead and sign the form and date it the date of the physical with all the information," Stokes says. "Then if the association wants another physical, the school explains it to the parents so we don't look like the bad guys."

Good practice: Your first step should be to ask patients to pay cash for the sports physical (especially those with insurance you know doesn't cover the service). If the parent insists that insurance will cover the exam, assure the family that your practice will file a claim and reimburse the parent if insurance does pay.

If the patient's insurance includes a yearly preventive medicine service, you can offer that service in lieu of the sports physical and maximize the patient's benefits -- pluskeep your coding clean. AAP recommendations supportthis approach.

"Many of our clinics will perform the full preventive medicine service at the time the patient presents for a sports physical," says Wolf. "Adolescents and teens are age groups that do not tend to come in regularly for their preventive services, so our clinics try to take advantage and get the complete well visit done at that time."

New tactic: Your coding will change if you're able to provide a preventive care visit. Choose the best code from 99381-99385 (Initial comprehensive preventive medicine evaluation and management of an individual ...) based on the patient's age for a new patient or from 99391-99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual ...) based on the patient's age for an established patient.

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 over 18, shift to V70.0 (Routine general medicalexamination at a health care facility).

Watch for additional coding opportunities with these patients, because a sports physical might extend to include other services.

If the pediatrician provides a problem-oriented E/M service for a separate, significant problem in addition to the sports physical or preventive medicine service, you also can code for it.

Next step: Once you select the appropriate E/M code, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to that E/M code and include documentation supporting the care as an additional service.

You should be able to link the E/M code to a specific diagnosis for the problem addressed, such as 493.00 (Extrinsic asthma; unspecified) for asthma that is well controlled with medication or 314.01 (Attention deficit disorder; with hyperactivity) for ADHD managed with stimulant medications.

Another challenge with sports physicals lies in the ever-growing number of "retail" clinics that offer quicker testing and less costly services. Stokes and Wolf agree,however, that convenience doesn't equal quality.

"We don't do what people call the quick sports physical," Stokes says. "We understand the parents want something fast, but we're clearing these kids to play sports and we have to take the appropriate amount of time to make sure they're in good health to play."

"Many of the primary care pediatric clinics in our network have countered the retail clinics by offering 'walk-in' services during regular clinic hours," Wolf adds. "They also offer extended weekend and evening hours."