Pediatric Coding Alert

Question: When a patient reports to our pediatrician for a school- or sports-related physical, how should we report the service?

South Dakota Subscriber

Answer: When these patients report for physicals, your coding will depend on the type of encounter, the patient’s status and some payer peculiarities. Check out these tips on physical coding and keep your practice’s bottom line ship-shape.

Though CPT^®  contains no specific codes to report a physical specifically for school or sports, you can often use an E/M code for the encounter.

When? If the patient has not had a full preventive service within the last 12 months at the practice, the provider can combine the school/sports physical with the annual well check. The pediatrician performs the full preventive service, and then fills in the school/sports form based on the results of the preventive service.

The appropriate code for these preventive visits depends on patient status and level of encounter. You’ll choose from:

• 99383-99385 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient...) for new patients and
• 99393-99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual...) for established patients.

If the patient had a preventive medicine exam within the past couple of months, you might be able to use the information gleaned from that visit to fill out a school/sports form.

Caveats: For one, your pediatrician filling out a school/sports form is not a codeable service. Further, signing off on these forms without seeing the patient is risky, for liability reasons. Because of possible liability, the pediatrician may not want to sign the form without checking the patient to see if his status has changed.

Since the code descriptors for 99383-99385 and 99393-99395 often bear little resemblance to what actually occurs during a school/sports exam, you might not be able to choose these codes for your provider’s services. If a provider is going to use these codes, then he must satisfy the criteria for the code during the encounter.

Do this: Go back and check the notes on any school/sports physical service. If the service does not meet the criteria for 99383-99385 or 99393-99395, check for evidence of a brief, detailed, or extended history and examination. If you can find these elements in the encounter, then you might choose the appropriate level E/M code instead (99201-99215).

If, however, the visit does not meet the criteria for a preventive medicine visit and the notes do not document a full history and examination, you might report unlisted-procedure code 99499 (Unlisted evaluation and management service). Check with your payer to see if this is something you can code 99499 for sport/camp/school physicals. If the payer accepts 99499, you might need to include a letter explaining the provider’s actions during the 99499 service.

Last resort: All of the aforementioned coding options are potential solutions for your school/sports physicals. Before choosing any of the options listed above, check with the payer to ensure you are coding according to its conventions. If you cannot find a way to rightfully code for the physical, you’ll have to bill the patient for the service — or provide it for free.