Pediatric Coding Alert

Parents can choose covered annual or self-pay exam.

Your pediatric practice probably gets calls all year-round from parents requesting sports physicals for their children. Although the physical may be fairly simple to perform, it isn't always straightforward to code. If you're at a loss for how to code a sports exam, consider these options that will put your CPT coding on the proper path while dodging nonpayment issues.

Strategy 1: Perform Less and Code Office Visit

When a pediatrician provides a true sports exam, CPT offers no direct match. Pediatricians may provide a shortened well-care visit, in which they assess the risks, perform an exam, and order vaccine and labs.

Problem: The shortened well-case visit encounters do not necessarily include the counseling and anticipatory guidance components of a regular wellcare visit, says Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville.

You should not report a sports exam using 99384-99385 for new patients (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 appropriate immunization[s], laboratory/diagnostic procedures, new patient ...) or 99394-99395 for established patients (Periodic comprehensive preventive medicine reevaluation and management of an individual ...).

A sports physical is not in and of itself a preventive medicine visit in history, physical examination, medical decision-making, and content, Tuck says.

Solution: A sports exam, when not included in a preventive medicine encounter, is an office E/M visit. You can code it with these items:

• for the CPT code, report an established or new E/M visit (99201-99215, Office or other outpatient visit)
• link 99201-99215 to the ICD-9 code for an administrative examination (V70.3, Other general medical examination for administrative purposes).

If the physician uncovers a problem during the visit, 99201-99215 linked to the problem will especially support the visit. Insurers, however, may not consider V70.3 a covered diagnosis.

Strategy 2: Encourage Full Well Check

To avoid V70.3 non-coverage issues, try to schedule patients for preventive medicine services, rather thanfor sports physicals. Parents sometimes misinterpret the sports physical as the child or adolescent's complete annual physical examination. Having the patient come in for the annual ensures she receives the full service.

Code it: You would code a preventive medicine service as follows:

• Use the age and status appropriate preventive medicine service code, such as 99394 (... adolescent [age 12 through 17 years]) for an established patient who is 15 years-old.
• Link the adolescent preventive medicine service (99384 or 99394) to V20.2 (Routine infant or child health check) for children less than 18 years of age or the young adult preventive medicine service (99385, ... 18-39 years or 99395) to V70.0 (General medical examination; routine general medical examination at a health care facility) for adults. Check the payer's V20.2 cutoff age.

Strategy 3: Consider Forms Policy

For patients who have received a recent preventive medicine service, consider using that information to complete a sports form. Some pediatric practices have a set fee the patient pays for this service, such as a $20 forms fee.

Some practices will include completion of forms at the time of an E/M visit, but charge if the forms are brought in at another time. There is additional office overhead involved if the chart must be pulled and reviewed, the form completed, mailed, or faxed, and the chart refiled, Tuck advises.

Pitfall: For liability reasons, your physician may not want to issue a form without checking the patient to see if his status has changed.

Strategy 4: Charge Parent

When a parent insists or the school requires an abbreviated exam on a patient who has not had a well check in the previous half of the year, you might want to implement a financial plan. Physicals required for sports are usually the patient's responsibility. Insurers typically do not cover the service.

Best practice: If you expect the insurer will not cover the sports physical, have the parent sign an advance beneficiary notice (ABN). Make sure the parent understands she will have to pay if the insurer does not cover the sports exam, and notify her of the price.

Tool: You can use a private payer version of Medicare's form (www.cms.hhs.gov/BNI) to educate the parent and ensure she is aware of her choices and responsibilities.

Strategy 5: Check State Scope of Practice Laws

Once you decide on the best strategy for your practice, confirm that your state allows you to use that technique. For example, certain states publish guidelines indicating that a physical done within the last 12 months is sufficient and the patient does not require an updated form, whereas other states require children to bring in new forms for each individual sport they plan to play.