Primary Care Coding Alert

Hint: Check with payer before reporting annual wellness or E/M related codes.

If your FP performs sports physicals, you will need to know how to report this service, as you do not have a straight forward code to report the encounter. You will need to broach all the available options, so you will receive appropriate payment for the encounter.

Here are three options for your consideration.

Choice 1: Try Reporting a Preventive Services Code

When your clinician performs a sports physical, you will not find an explicit code to report the visit. You may wonder whether you can report a sports physical with a preventive medicine code.

However, you should remember that, during sports physicals, your clinician might not perform the type of comprehensive age and gender appropriate history and examination that is otherwise associated with reporting a preventive medicine code. Also, your FP might not perform any counseling or other anticipatory guidance or order any laboratory/diagnostic procedures as described by a preventive medicine code.

“Preventive medicine visits, as described by CPT^® codes 99381-99397, are more comprehensive services than the typical sports physical,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Thus, while you might include a sports physical in a preventive medicine service, such as an annual physical, a sports physical by itself does not typically constitute a preventive medicine service as described by CPT^®.”

So, if your clinician only performs a sports physical, you should probably not report the service with a preventive medicine code. But you can try to include the sports physical as a part of the regular annual physical if the patient has not already had his/ her annual physical in the past twelve months. “If a physical is performed and a form needs to be completed, that should be acceptable to bill as the normal physical,” says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, senior principal of ACE Med, a medical auditing, coding and education organization in Pittsburgh, Pa.

If the patient has not had their annual physical when he/she tries to set an appointment with your FP for a sports physical, you could let the patient know that they have not had their annual physical, and they could combine the annual physical with the sports physical.

If your FP performs the sports physical with the annual preventive service, you can report an appropriate code from the range 99382-99387 if the patient is new or from 99392-99397 if the patient is an established patient.

You will have to make an appropriate choice depending on the age of the patient. You will have to report an appropriate diagnosis code to support the preventive examination that your FP performed. You can look at Z00.129 (Encounter for routine child health examination without abnormal findings) when your clinician performs the preventive service for a person aged below 18. Select Z00.00 (Encounter for general adult medical examination without abnormal findings) when your clinician performs the service for a person who is aged 18 or above.

“If this is a visit in addition to the already performed yearly physical then, you should not report it with a preventive medicine code,” Hauptman says. “It should be considered non-covered or covered by the school or program requesting it.” If the patient has already had an annual preventive medicine service, especially recently, you could ask your clinician to fill the sports physical form from the information that was captured during the preventive visit. However, you will not be able to report the sports physical as a separate visit and report it with another preventive medicine code.

Choice 2: Look at Reporting an E/M Code

Since you cannot always look at reporting a sports physical as part of a preventive medicine visit, you may have to look at other alternatives for reporting this service when your clinician performs it separate from a preventive medicine service.

Another option that you might broach to report sports physicals is to see if the payer will allow you to report a different E/M code for the visit. As per the American Medical Association’s CPT® Assistant, you can report an E/M code only if your clinician performs a brief, detailed, or extended history and examination.

So you can report an appropriate code from 99201-99215 if the encounter satisfies all the components of reporting such an E/M code and if the payer will allow you to report an E/M code for the sports physical. You will have to support the code that you are reporting with a diagnosis code such as Z02.5 (Encounter for examination for participation in sport).

However, some payers might not provide coverage for sports physicals with an E/M code as you typically report an E/M code for a problem-related encounter. Since a sport physical is a general examination and the patient will not generally have any chief complaint or your clinician will not arrive at a medical problem-related diagnosis, you may not be allowed to report an E/M code for the encounter.

Best bet: Check with the payer beforehand if they will allow you to report an appropriate E/M code for a sport physical, so you will not face a denial if the payer will not allow you to do so.

Choice 3: Charge the Patient for the Service

If the patient has already finished their annual wellness visit prior to approaching you for a sports physical, you typically cannot report a preventive medicine service code for the service. If the payer will not allow you to report an E/M code for the sports physical, then you cannot report any other codes to the patient’s insurance.

In such a case, you are left with no other option but to charge the patient for the service. You will need to inform the patient that the sports physical cannot be billed to the patient’s insurance as it is not a covered service and the patient will need to pay from pocket for the service. You need to inform the patient before they see your clinician for the service, so they are informed that it is a self-pay visit, which will help you avoid unnecessary altercations with the patient. You can also get the patient to pay up front and say that you will try to submit the claim to insurance and if you get paid from the insurance, they will receive their money back.

Example: An established 11-year-old male patient needs a sport physical to participate in annual sports. The patient has already had his wellness visit about five months back. You contact the payer and find out that their policy will not allow you to report an E/M code for the sports physical. Your clinician sees the patient for the sports physical, performs the examination of the patient, and fills in the relevant forms that the patient has carried.

What to report: Since the patient has already had his annual physical, you cannot report 99393 (…late childhood [age 5 through 11 years]) for the visit. As the payer will not allow you to report an E/M code for the visit, you will have to inform the patient’s parents that the sports physical is not a covered service. So, you cannot bill the patient’s insurance for the service, and the parents will have to pay for the service themselves.