Pediatric Coding Alert

 Tip: Look to service's extent, focus when coding 3 well-patient visits Even though a sports exam, a school physical and an annual exam each deal with healthy children, you shouldn't assume all these services count as a preventive medicine service.
 
CPT doesn't contain specific codes for sports exams and school physicals. So you may not know how to code these encounters. But, if you look at what the service focuses on and the elements that you document, you should achieve flawless well-patient visit coding. Sports Exam Assesses Athlete's Fitness Of the three types of wellness exams that you usually perform, a sports exam focuses on the patient's fitness for the designated sport. The extent of the history, examination, medical decision-making and counseling depends on the child and what you're doing the exam for, says Victoria S. Jackson, administrator at Southern Orange County Pediatric Association in Lake Forest, Calif. "You may perform more or less work than you would for a preventive medicine service."
 
Youth sports may require you to perform a lower-level service than high-school sports. "For instance, sports exams for Pop Warner sports, such as Little League Softball, are very simple," Jackson says. A high-school sports exam may be more extensive.
 
Not sure which areas the encounter should cover? A sports exam could include the following elements, says  Charles A. Scott, MD, FAAP, pediatrician at Medford Pediatric & Adolescent Medicine PA in Medford, N.J.
 
History:
  any past injury and rehabilitation the athlete may have had
  medicines or conditions that may impact the patient's sport participation, such as asthma

Examination:
  a joints, extremities and cardiovascular exam
  flexibility and other sports-appropriate fitness assessments

Decision-making:
  determining whether any condition the patient has, such as a heart murmur, requires further consideration, like an echocardiogram (ECG), because the sport requires the patient's body to work harder
 
Counseling:
  injury prevention including pointers on warm-ups, overuse, proper rest, and water intake
  substance-abuse awareness that focuses on drug and alcohol use.
  proper diet and sports nutrition. School Physical, Annual Are Age-, Gender-Specific
 
In contrast, a preventive medicine service and school physical don't evaluate the patient's fitness readiness. They instead focus on a general overview of the individual, including an age- and gender-appropriate history and exam, says Richard Tuck, MD, FAAP, a member of the American Academy of Pediatrics' national committee on coding and nomenclature. "You spend less time addressing sports-specific elements."
 
You should report a preventive medicine service with 99381-99397, says Sherry Wilkerson, RHIT, CCS, CCS-P, coding and compliance manager at Catholic Healthcare Audit Network in Clayton, Mo. A preventive medicine service involves an age- and gender-appropriate history (including review of systems; past, family, social history; and risk-factor assessment) and a multisystem examination.
 
A school physical requires about the same amount of work that CPT requires [...]