Practice Management Alert

Tip: Consider combining physician services to make the most of physician time

Stop sacrificing payment or, worse, patient satisfaction when it comes to school, sports and camp physicals. You can collect for these services without fraudulently billing a preventive exam. Get a jump on these exams by following these three best practices.

Option 1: Collect From the Patient

When a patient comes in for a school or camp physical that his carrier won't cover, you can collect from the patient directly.

-My suggestion is that these are treated as -self-pay- services and offices should collect up front,- says Christy Neff, RMC, physicians billing specialist for Witham Health Services in Lebanon, Ind. -If the patient/parent insists that insurance will cover the exam, we can file a claim, and then if insurance does pay, we will reimburse the patient/parent.-

First step: Inform parents that, unlike annual preventive medicine services, sports and camp physicals are usually noncovered services and their payer may not pay for the service, says Charlene Burgett, MS-HCM, CMA, CMM, CPC, CCP, CMSCS, administrator for North Scottsdale Family Medicine in Arizona. Then, you can charge the parent or guardian up front when your physician fills out school or camp paperwork and/or performs a noncovered physical exam.

Tip: If you-re billing the patient directly for a non-covered service like this, you don't need to submit anything to the insurance company. If the patient insists that you do, however, you should submit the claim.

Many patients have the misconception that payers will pay for everything, and when you tell them something is not covered, they don't believe you. For good patient relations in these cases, bill the claim. Indicate in the appropriate field of the claim the reason for the claim submission, such as -need denial for secondary insurance- or -need denial for patient.- If you-re billing to Medicare in order to get a denial, be sure to append modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or for non-Medicare insurers, is not a contract benefit).

Best bet: -When in doubt, have the patient pay up front, submit the claim to the insurance, and if they pay, you can reimburse the patient,- Neff says.

Option 2: Combine an Annual and School Physical

You can recoup preventive exam pay if your patients present for their annual exam when they require a sports or camp form. Encourage parents to schedule their child's annual physical around the time that they-ll need forms filled out for school or camp.

-If the child is due for a normal well child check, we will typically perform that service and just fill out the camp/sports/school physical at that time,- Burgett says.

Good news: Some insurers cover 99382-99385 (Initial comprehensive preventive medicine evaluation and management of an individual - new patient) and 99392-99395 (- established patient) annually, so you could collect reimbursement for the service. Therefore, if the patient has not had a full preventive service in the last 12 months, you can inform the parent when he calls for an appointment that the physician will perform the full preventive service and you-ll bill to the insurance. Then the office can fill in the school, sports or camp physical form in conjunction with the preventive visit.

-Studies show that about half of pediatricians bill sports physicals as preventive medicine services if the patient has not had one in the past two years,- says Joel Bradley Jr., MD, FAAP, a pediatrician with Premier Medical Group in Clarksville, Tenn. Because the physician can set the agenda for the preventive medicine service (PMS), you can correctly code sports exams with PMS codes.

Example: An established 15-year-old female patient requires her annual exam and a sports exam to play school soccer. You should use 99394 (Periodic comprehensive preventive medicine reevaluation and management ... established patient; adolescent [age 12 through 17 years]) for this service. Assign the routine general medical examination code V70.0 (Routine general medical examination at a healthcare facility) to inform the insurer that the physician performed a health checkup.

Alternative: You may also use information from a recent preventive medicine service exam to fill out a patient's school, sports or camp form, but you probably can't bill a separate service to the insurer or the patient for this.

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

Watch For E/M Pitfalls

Remember that if the physician does not have documentation of a full comprehensive history and age-appropriate comprehensive examination, you should report unlisted-procedure code 99499 (Unlisted evaluation and management service).

Caution: Keep in mind that E/M visit codes are only for -problem-oriented- services, so if your physician is only performing a sports physical, for example, -billing with a 99212-99215 would be inappropriate. Since you won't have a chief complaint or medical diagnosis, submitting these codes could be considered fraud,- Neff says.

Neff also offers the following important tips of what not to do when billing school, sports or camp physicals:

- Do not submit a preventive code with modifier 52 (Reduced services).
- Do not report 97005 or 97006 (Athletic training evaluation) because these codes represent problem-oriented services, such as a sports injury.
- While it is common for patients to ask the physician to code the visit as a problem-oriented visit so that it will be paid, this constitutes fraud. Don't do it.