Eli's Rehab Report

Question: A fellow coder recently suggested reporting codes 97005 and 97006 for sports physicals. Are these codes really applicable, and will we be reimbursed if we use them?


Arizona Subscriber

Answer: One crucial element of 97005 (Athletic training evaluation) and 97006 (Athletic training re-evaluation) renders these codes inapplicable to sports physicals - these codes represent problem-oriented services, such as, recognition and evaluation of an athletic injury, formulation of a treatment plan/intervention, and educational training for a specific injury.

To report a sports physical, a non-problem-oriented evaluation of a patient for certification for involvement in organized sports, you could choose an age-appropriate preventive medicine code. To use the preventive medicine series of codes, 99381-99397, the physician must perform and document a comprehensive (age- and gender- appropriate) history and examination.

For many sports physicals, the history and exam performed is not synonymous with a well-child exam performed by their primary-care provider. If the physician does not have documentation of a full comprehensive history and examination, you should report the appropriate-level office visit (E/M service) or other outpatient E/M visit code.
 
Link the most appropriate CPT code to diagnosis code V70.3 (General medical examination; other medical examination for administrative purposes). FYI: Many insurance companies may not reimburse for an E/M visit code linked to V70.3. You should check with the payer to see if a sports physical is a covered benefit or if the visit should be the patient's responsibility.