Pediatric Coding Alert

This is the time of year when many pediatricians are busy doing annual physicalsand sports physicals. Coding for sports physicals presents a big problem for pediatric practices because most payers wont reimburse for more than one well-visit per year. Each year we submit claims to the insurance carrier [for sports physicals] and the claims are denied, states Delores Butler, office manager for Cumberland Pediatrics of Smyrna, GA. Please let me know the codes we should be using in order to obtain reimbursement from insurance companies.

Butler hits the nail on the head when she focuses on reimbursement here. Because no matter what code you use, many sources say, you are probably not going to get reimbursed for doing more physicals a year than the health plan will allow, usually one well-visit per year for young children and one visit every other year for older children, although there are exceptions. We talked to two different practices about how they handled this problem.

1. Make the sports physical the same as the annual physical. This is the number-one recommendation we received. What we recommend is that sports physicals become the annual physicals, says Shelley Leeds, business office manager for Fairfax Pediatric Associates in Fairfax, VA. We tell the parents that if theyll need the sports physical, they should switch the [annual] physical to the appropriate time of year.

2. Use the annual physical for the sports physical. This is a variant of the solution advocated in No. 1. Lynn Bloom, insurance administrator for Maple Avenue Pediatrics, a four-pediatrician practice in Fair Lawn, NJ, says her practice does the yearly physical, and, when the sports physical is needed, the nurse fills out the forms. If they had a physical in January, and need a sports physical in June, we fill out the history then, she says. Filling out the form doesnt require the doctors time, so we dont code for it.

3. Extra work. Sports physicals have some extra requirements that regular physicals dont have, but Leeds says these just have to be incorporated into the regular physical. This is why it makes sense to schedule the sports physical as the well-visit, she says. The same concept can apply for camp physicals, she adds.

Procedure Codes for Annual Physicals

New Patients

99381 age under 1 year
99382 1 through 4 years
99383 5 through 11 years
99384 12 through 17 years
99385 18 through 39 years

Established patients

CPT 99391 age under 1 year
99392 1 through 4 years
99393 5 through 11 years
99394 12 through 17 years
99395 18 through 39 years

The diagnosis code is V20.2 *