Pediatric Coding Alert

Your notes will need to reflect the option you choose

Before you attend to your next sports exam, make sure you nail down the requirements necessary for the E/M service you report. Otherwise, your coding might not be on the ball.

Check if Work Counts as 99393-99394

Despite all the rumors about sports exams not qualifying for preventive medicine services codes, you shouldn't rule out using 99393 (Periodic comprehensive preventive medicine reevaluation and management of an individual ... late childhood [age 5 through 11 years]) and 99394 (... adolescent [age 12 through 17 years]). "Studies show that about half of pediatricians bill sports physicals as preventive medicine services if the patient has not had one in the past two years," says Joel Bradley Jr., MD, FAAP, a pediatrician with Premier Medical Group in Clarksville, Tenn. Because the physician can set the agenda for the PMS, you can correctly code sports exams with preventive medicine service codes.

Key: Before classifying a sports exam as a preventive medicine service, check the work involved in the encounter. Codes 99393-99394 require a comprehensive reevaluation and management. But the "comprehensive" nature "reflects an age- and gender-appropriate history/exam and is NOT synonymous with the 'comprehensive' examination" that the higher-level E/M codes within 99201-99350 require, states the AMA in CPT's introductory preventive medicine services notes.

Try Problem Visit for Less Involved Cases

You may have shied away from coding sports exams with 99393-99394 due to warnings about not using the codes for encounters involving less than a comprehensive history and examination. "If the physician performs a problem-focused, expanded problem-focused or detailed history and examination, then report the appropriate-level office or other outpatient evaluation and management visit code," the AMA says in the 1999 CPT Companion book.

Watch Out for V70.3 Auto Rejections

But using an office visit code for a sports exam can trigger an auto rejection. "A sports exam is a NON-problem-oriented visit," says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders based in Salt Lake City. Because office visit codes are for problem-oriented services, using these codes for a sports exam doesn't properly represent the service's purpose. In addition, the ICD-9 code associated with a sports exam (V70.3, General medical examination; other medical examination for administrative purposes) mismatches 99201-99215's problem intent.

Best bet: Check with insurers before using 99201-99215 with V70.3 for a sports exam. "Many payers' claims processing systems automatically reject claims that list problem-oriented visit codes with preventive-oriented diagnosis codes," says Cindy Hughes, CPC, in "Sports Physicals: A Coding Conundrum," which appeared in the October 2006 Family Practice Management.

Does Documentation Support E/M Level?

When you use an office visit code for a sports exam, make sure your documentation supports the level of service you're reporting. Pay attention to the code's chief complaint and key components. Because the requirements for an office visit are problem-related, you might have a struggle getting documentation to support the level of service you're reporting. "Using an office visit code to bill for a sports physical is like trying to fit a square peg into a round hole," Hughes says.

Consider a Nontraditional Approach

While experts have weighed in on the risks of classifying a sports exam as a preventive medicine service and office visit, one avenue remains untried. When the encounter's work doesn't meet the criteria for 99393-99394 of an age- and gender-appropriate history/examination because no other code specifically describes the sports exam as a well service, you should use 99499 (Unlisted evaluation and management service), Cobuzzi says.