Primary Care Coding Alert

Its an annoying but real fact of life for billers for family practices: patients or parents want to make an appointment for no medical reason, not even specifically for their annual well-visit, but rather because school, camp, or a job requires a physical.

Unless the patient is going to pay out of pocket for this visit, you have only one coding option, our experts say: preventive medical services (99381-99387 for new patients, 99391-99397 for established patients).

Physicals are usually given in the absence of any complaint, notes Kent Moore, manager of reimbursement issues for the American Academy of Family Physicians. Since there is no complaint except the need for a form to be filled out for these physicals, these preventive medicine services codes are the most appropriate, he explains. But a question may arise as to whether the physician is fulfilling the comprehensive history and exam requirements of these codes, he says. For example, you may only do a brief, detailed, or extended history if you are only doing a work physical. This, some people believe, would warrant an office visit code rather than a preventive medicine services code. However, you would be using a well-visit diagnosis code (either V20.2 for a child or V70.0 for an adult). The V code doesnt fly with an office visit, notes Moore. So my best advice is to use the preventive medicine code whether you do brief, detailed, extended, or comprehensive, he says.

Commercial vs. Medicare

Since Medicare doesnt pay for preventive medicine services, most of these situations come up with commercial plan patients. The best way to get these physicals paid is to do a full-scale physical, and make it the one that the health plan pays for that year, our experts say. If the patient has already had the physical for that year, and the work or school is demanding another, then the patient has to pay, says Alison Smith, CCS, coding manager for Sentinel Health Partners of Fayetteville, Ga. You have to explain this to the patient up front.

Caroline Pelton, billing and insurance manager for Berkeley Springs Medical Associates in Berkeley Springs, W.Va., says, Basically, there isnt a lot of extra paperwork, and we use the V code and get paid with no problems.

Patient Payment

If, however, you are concerned about reimbursement, particularly in terms of the number of allowed physicals (some health plans only allow one every three years, for example, and some employers or schools or camps may require them yearly), you need to make sure the patient will pay you. One option is to collect the money up front from the patient, and then file for the insurance, reimbursing the patient if the insurance company covers the physical.

Some practices take a different tack and dont bother seeing the patient again if there has already been a physical that year. Instead, they just fill out the paperwork. Theres no way of getting reimbursed for the time the nurse spends doing that. However, this isnt recommended. If the employer or school required the physical to be current, because of possible liability if there is a health complication, and it is determined that the practice filled out the paperwork without performing an exam, the physician could be liable.

Note: Informing patients that they will be responsible for payment, and having them sign a waiver noting it is not a covered service will help when collecting reimbursement.