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Pediatric Coding Alert

Sports Exam Is Similar to Checkup in Face Value Only

Published on Sun Nov 14, 2004

 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 for a preventive medicine service. "A simple school physical and regular checkup are virtually synonymous," Scott says. In either exam, you
    don't need to check as extensively on the patient's flexibility or cardiovascular status.

    Service's Extent Determines Coding

    An encounter's focus gives you a clue to the type of service that you perform. But to code a sports exam or school physical properly, you must check the extent of the service that you provide.
     
    Here's how: You should code sports and school physicals based on these guidelines:
     
    1. If the physician performs a comprehensive history and examination, you should report the age-appropriate code from the preventive medicine series. Use 99383-99385 (Initial comprehensive preventive medicine evaluation and management of an individual ...) for a new patient annual exam and 99393-99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual ...) for an established patient well check.
     
    2. If the physician performs a problem-focused, expanded problem-focused or detailed history and examination, report the appropriate-level office or other outpatient evaluation and management visit code, such as 99201-99215 (Office or other outpatient visit for the evaluation and management of a new or established patient ...). Select the appropriate-level E/M code based on the history, examination and medical decision-making that you perform and document.

    Reimbursement Is Uncertain

     If you use a sports exam or school physical diagnosis, you could run into reimbursement problems. "Some payers will not pay for the diagnosis code that you would typically use for school/sports physicals, which is V70.3 (Other medical examination for administrative purposes)," Wilkerson says. Insurers sometimes deny V70.3 as noncovered because the plan benefit design does not include an exam or a physical.
     
    Solution: If the insurance company considers a sports exam a noncovered service, you may charge the exam fee to the patient.

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