Primary Care Coding Alert

See how well you can identify the correct CPT^® codes.

Once you’ve answered the quiz questions on page 3, compare your answers with the ones provided below.

Answer 1: The best CPT® codes you can use to report school, sports, and work physicals are the age-appropriate preventive medicine service codes:

• 99382-99387 (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 laboratory/diagnostic procedures, new patient...) for new patients and
• 99392-99397 (Periodic comprehensive preventive medicine reevaluation and management of an individual...) for established patients.

The services themselves cover all the bases for school, sports, or work, as long as the provider thoroughly documents the visit, including growth and developmental milestones for younger patients, the psychological health of older patients, and all the other age- and gender-appropriate components required. Most, if not all, payers will reimburse without much trouble. This is also the best way to help prevent the patient from having to pay for the service out of pocket, since these codes typically don’t involve patient cost-sharing. You’ll want to pick the one that best suits the encounter.

This may require some communication between the practice and the patient to try to coordinate the physical exams around peak times for school and sports seasons to avoid the need for a second physical later in the year.

This brings us to the next answer.

Answer 2: “Most payers only pay for one preventive physical exam per year,” explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. This can get tricky, but there are a few options if the patient already had their annual checkup. One option is to simply code using one of the aforementioned CPT® preventive codes. If the patient had a preventive medicine exam within the past couple of months, you might be able to use the information gleaned from that visit to fill out a school/sports form. It should also be noted that if the provider deems the recent preventive exam current enough, just filling out the form does not warrant an E/M service code.

If it’s been closer to a year since the last physical, the physician may consider that information too outdated. The primary care practitioner (PCP) in this instance may require that the patient come in for another exam. If this is the case, and the service does not appear to meet the criteria for 99382-99387 or 99392-99397, check for evidence of a brief, detailed, or extended history and examination. “Are there other problems being managed during the visit? This question will help the provider and coder assess if it’s best to utilize the E/M codes (99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) instead,” says Keisha Wilson, CCS, CPC, CRC, CPMA, CPB, approved instructor, KW Advanced Consulting, LLC in Brooklyn, New York. If you can find these elements in the encounter, then a regular E/M code might be the way to go. One challenge with this strategy is that codes 99202-99215 involve medical decision making that is not typically part of a school, sports, or work physical and may not be supported by one of the diagnosis codes discussed below.

If, however, the visit does not meet the criteria for a preventive medicine visit and the notes do not support a problem-oriented office/outpatient E/M service, you might report unlisted-procedure code 99499 (Unlisted evaluation and management service). Check with your payer to see their policy on reimbursing code 99499 for sport/camp/school/work physicals. If the payer accepts 99499, you might need to include a letter or other information explaining the provider’s actions during the encounter.

Note: All of these coding options are potential solutions for your school/sports/work physicals. Before choosing any of the options listed above, check with the payer to ensure you are coding according to its rules. If you cannot find a way to rightfully code for the physical, you’ll have to bill the patient for the service. If you anticipate that will be the case, you may want to alert the patient (or parent) ahead of time, so there are no surprises later.

Answer 3: Which diagnosis code(s) you will use will depend on documentation in the patient record as well as the reason for the visit. If the patient is combining their annual visit with the school-required physical, “the appropriate ICD-10 diagnosis code for the routine visit must be the primary diagnosis,” says Wilson. This will most likely mean reporting Z00.129 (Encounter for routine child health examination without abnormal findings) or Z00.121 (Encounter for routine child health examination with abnormal findings). Then report a Z02.- code, such as one of the ones from the following list, as the secondary diagnosis code:

• Z02.0 - Encounter for examination for admission to educational institution
• Z02.1 - Encounter for pre-employment examination
• Z02.2 - Encounter for examination for admission to residential institution
• Z02.3 - Encounter for examination for recruitment to armed forces
• Z02.5 - Encounter for examination for participation in sport
• Z02.89 - Encounter for other administrative examinations (which includes examinations for admission to summer camp)

If the annual visit and school-required physical are not combined, report only the appropriate Z02.- code.

Answer 4: Yes, you can absolutely bill separately for any vaccines administered during the physical exam. Report the appropriate code(s) for vaccine administration, such as 90460/+90461 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional …) along with the appropriate code for the vaccine/toxoid product(s). Per CPT® guidelines for the preventive medicine E/M service codes, “vaccine/toxoid products, immunization administrations, ancillary studies involving laboratory, radiology, other procedures, or screening tests (eg, vision, hearing, developmental) identified with a specific CPT® code are reported separately.”

Along similar lines, “all screening and testing services can be billed with any E/M service, whether it be a preventive or a sick visit E/M, under appropriate circumstances,” according to Falbo. This means that vision screens such as 99173 (Screening test of visual acuity, quantitative, bilateral) and hearing screens such as 92551 (Screening test, pure tone, air only) can be billed alongside developmental screens such as 96110 (Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument) and behavioral screens such as 96127 (Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument) when appropriate and depending on the patient’s age and development.

Note: If reporting 99173 in addition to a sick visit E/M, you may need to append a modifier (such as 59, Distinct procedural service) to 99173, since National Correct Coding Initiative edits otherwise bundle 99173 into 99202-99215. These edits are consistent with parenthetical instructions following 99173 in CPT®. Those instructions state, in part, “When acuity is measured as part of a general ophthalmological service or of an E/M service of the eye, it is a diagnostic examination and not a screening test.”

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