Primary Care Coding Alert

These useful strategies assure revenue despite scant insurer coverage.

Very soon, a rush of young kids will be looking to their family physicians for medical clearance to participate in sports. Commonly referred to as sports physicals, they present unique problems to coders, especially concerning their coverage by insurers. To avoid loss of revenue and to maximize the earning potential of your practice, here are some surefire tips on coding for sports physicals.

When Unsure of Coverage, Ask for Cash

To ensure revenue for your practice, you can ask patients, especially those with insurance that you know does not cover it, to pay cash for the sports physicals. "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." When coding for a sports physical, use V70.3 (Other medical examination for administrative purposes).

Maximize Your Patient's Annual Preventive Benefits

If your patient's insurer provides annual preventive medicine service, then, when possible, do this in lieu of the sports physical. For insurers that otherwise cover preventive medicine services but not sports physicals, you may be able to avoid V70.3 noncoverage issues, by scheduling patients for preventive medicine services (99318-99397), 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.

General preventive medicine visits involve diagnosis codes other than V70.3. Specifically, for a routine infant or child health check, you can use V20.2 (Routine infant or child health check), which ICD-9- CM denotes as a pediatric code that includes kids up to age 17. For kids over 17, consider V70.0 (Routine general medical examination at a health care facility).

Alternatively, when your patient has had his annual exam done within the year, then you can simply fill out his forms. Some charge a fee for this while others do it for free. It really depends on your practice. "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. "6 Strategies to Improve Your Preventive Billing Pay-Up."

Catch E/M Service

During a visit for a sports physical, the doctor may have done more than just a sports physical. If a problemoriented E/M service was provided by the doctor in addition to the sports physical or preventive medicine service, then code for it also. This is consistent with CPT guidance, which states, "If an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported."

You will need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the problem-oriented E/M code in this scenario. Common conditions that potentially may require an E/M service during a preventive service may include asthma, congenital illnesses, and other chronic conditions.