Pediatric Coding Alert

Question: Our practice has so much trouble getting reimbursed for sports physicals. I just discovered CPT 97005 and 97006 as possible codes for this type of visit. Is this correct coding?

Arizona Subscriber

Answer: The physical medicine and rehabilitation codes 97005 (Athletic training evaluation) and 97006 (Athletic training re-evaluation) are not appropriate for the typical sports physical. From a CPT perspective, these codes are generally intended to be problem-oriented, and they include recognition and evaluation of an athletics injury as well as educational training related to the specific injury. Athletics training also includes management and recommendations for treatment of an athletics injury. These services are most commonly provided by athletics trainers.
 
In comparison, a sports physical is typically a non-problem-oriented encounter in which a physician evaluates and certifies a patient's involvement in organized sports, such as high school football or basketball. If your pediatrician performs a comprehensive history and examination, you should report the age-appropriate code from the preventive medicine series (99381-99397). If the physician performs less than a comprehensive history and examination, report the appropriate-level office or other outpatient evaluation and management visit code, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).
 
Typically, you would use diagnosis code V70.3 (General medical examination; other medical examination for administrative purposes), which includes general medical examinations for sports competition, for a sports physical. Some payers, however, will not accept a "well" diagnosis with a "sick-visit" code (99201-99215). In this case, you should collect payment for the visit in cash up-front provided your contract permits billing the parents.