Pediatric Coding Alert

Question: Our pediatrician reports code V21.1 (Puberty) when checking puberty level for sports. Our insurer is denying this code with 99213 as inconsistent with the CPT® code. Which ICD-9 code should we report instead? 

Answer: Because puberty is a “normal” state, it won’t typically support reporting of a problem-oriented E/M code. 

If no problems were addressed during the visit and the doctor only did the sports physical, you probably can’t report a problem-oriented E/M code like 99213. Instead, you’ll bill a preventive medicine visit such as 99394, Periodic comprehensive preventive medicine reevaluation and management of an individual ... adolescent [age 12 through 17 years]). The need for a sports physical provides an opportunity to get that adolescent in for their preventive visit, often ignored by adolescents and their families.

If you’ve already given the athlete his preventive medicine service for that year, you may be able to report a preventive medicine visit but chances are high that the insurer won’t pay you for it. In this case, you should inform parents that sports physicals are often noncovered services and that you expect payment up-front for the service.

Note: There is an ICD-9 code for a sports exam (V70.3, Other general medical examination for administrative purposes) and a comparable code in ICD-10 (Z02.89, Encounter for other administrative examinations).