Primary Care Coding Alert

Plan your coding, payment policy attack now

You can boost reimbursement for spring and summer physicals if you implement some of the following strategies offered by our coding experts: 

1. Use a Dummy Code

You have to code for a sports or camp exam even if you don't bill the service to insurance. A wealth of alternatives exist.

You may consider reporting a low-level E/M code for the service. "We use 99211 (Office or other outpatient visit for the evaluation and management of an established patient ... typically, 5 minutes are spend performing or supervising these services) because the sports exam takes hardly any time," says Tammy Trench, CPC, accounts receivable technical advisor at Apex Practice Management in Oklahoma City.

Because insurers won't cover the sports exam service, 99211 serves as a data-entry method. "Reporting 99211 for a sports or camp exam is just our way of recording the service," Trench says.

Other coders stick with the preventive medicine service codes. For instance, Bon Secours Health Partners uses 99382-99385 (new patient preventive medicine services) or 99392-99395 (established patient preventive medicine services) for a sports exam. "Because the exam doesn't require a complete physical, we append modifier -52 (Reduced service) to the PE code," says Merlinda Craig, CPC, at Bon Secours Health Partners with one family physician in Shohola, Pa. "Camps usually require a more extensive exam, which we code as 99382-99385 or 99392-99395."

Watch out: CPT recently clarified that you shouldn't use modifier -52 with a preventive medicine service. When the FP performs only a brief history and examination, you should report the appropriate office or other outpatient E/M code (99211-99215) based on the physician's documented key components instead of appending modifier -52 to the preventive medicine service, states the AMA's CPT Information Services.

Problem: Using the sick visit code (99211-99215) makes the sports exam "well" diagnosis contradict the E/M service. "We use V70.3 (Other medical examination for administrative purposes) as the sports/camp exam diagnosis," Trench says. Because the coding is only for internal purposes, she doesn't have to worry about insurers rejecting the sick E/M, well diagnosis combination.

2. Combine Annual and Sports Exam

You can recoup preventive exam pay if you have patients come in for their annual exam when they require a sports or camp form. "Patients often need a spring and fall sports exam, plus a preventive exam for school," Craig says. "We encourage parents to schedule their child's annual comprehensive preventive medicine service at the same time the child needs a sports or camp exam."

Benefit: Insurers typically cover 99382-99385 and 99392-99395 annually. So, you should receive reimbursement for the service.

Coding: If the FP performs the full preventive exam, you should report the age-appropriate preventive medicine code, Craig says.

Example: For an established 12-year-old boy who needs his annual exam and also requires a sports exam to play junior-high soccer, you would use 99394 (Periodic comprehensive preventive medicine re-evaluation and management ... established patient; adolescent [age 12 through 17 years]). Use the routine general medical examination code V70.0 (Routine general medical examination at a healthcare facility) to inform the insurer that the FP performed a health checkup.

3. Collect Cash Up Front

Sometimes, however, patients don't coordinate the well check with a sports or camp exam. In this case, you should inform parents that sports and camp physicals are usually noncovered services. "We try to tell parents that insurers don't pay for these services," Craig says.

Solution: You can charge the parent cash up front for the service. "Most parents are happy to pay the $15 that we charge for the physician's child evaluation and form completion," Trench says.