Pediatric Coding Alert

Parents can choose covered annual or self-pay exam.

If you're at a loss for how to code a sports exam, consider these alternatives that will put your CPT coding on the proper path while dodging nonpayment issues.

Option 1: Perform Less and Code Office Visit

When a pediatrician provides a true sports exam, CPT offers no direct match. Coding for a sports physical is always an issue, notes Rita Adams with El Camino Pediatrics in Encinitas, Calif.

"Parents want a quick exam and release for the child for sports," Adams explains. The pediatricians provide a shortened well-care visit, in which they assess the risks, perform an exam, and order vaccine and labs.

Problem: "The encounters do not necessarily include the counseling and anticipatory guidance components of a regular well-care visit," Adams points out.

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 a preventive medicine visit in history, physical examination, medical decision-making, and content," says Richard Tuck, MD, FAAP, a pediatrician with PrimeCare of Southeastern Ohio in Zanesville.

Solution: "A sports exam is an office E/M visit," Tuck says. 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.

Option 2: Encourage Full Well Check

To avoid V70.3 non-coverage issues, try to schedule patients for preventive medicine services, rather than for sports physicals. "If the patient has not had a physical in the past six months, we have the parents bring him in for his annual well visit," recalls Victoria S. Jackson, former administrator/CEO of Southern Orange County Pediatric Associates Inc. and consultant with JCM Inc. in California.

Parents sometimes misinterpret the sports physical as the child or adolescent's complete annual physical examination, Tuck warns. 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.

Option 3: Consider Forms' Policy

For patients who have received a recent preventive medicine service, discuss with your staff using that information to complete a sports form. "Our policy is our physicians will fill out the form if the patient has had a physical in the past six months," says Jacqueline Stack, CPC, CPC-I, CPC-E/M, CCP-P, in Audioeducator.com's "6 Strategies to Improve Your Preventive Billing Pay-Up."

Some pediatric practices have a set fee the patient pays for this service. "We charge for all forms," reports Charles Scott, MD, FAAP, pediatrician at Medford Pediatrics and Adolescents in New Jersey.

Option 4: Charge Parent

When a parent insists on 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," notes Stack, who works for Seneca Medical Center in Oil City, Penn. 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), Stack suggests. "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.