Primary Care Coding Alert

Question: We are starting to get appointment requests from patients reporting for physicals, either for school or sports programs starting in January 2016. These patients are all aged late childhood to early adult. How should I code for a patient of this age that reports for a physical

Pennsylvania Subscriber

Answer: When a patient reports for a “physical,” your coding will depend on the type of encounter, the patient’s status, and some payer peculiarities.

Though CPT® contains no codes to report a physical specifically for school or sports, you can often use an evaluation and management (E/M) code for the encounter.

When? If the patient has not had a full preventive service within the last 12 months at the practice, the provider can typically combine the school/sports physical with the annual well check that most payers allow. In this situation, the physician performs the full preventive service and then fills in the required school/sports form based on the results of the preventive service.

The appropriate code for these preventive visits depends on patient status and level of encounter. You’ll choose from:

• 99383-99385 (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
• 99393-99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual...) for established patients.

Caveat: Since the code descriptors for 99383-99385 and 99393-99395 often bear little resemblance to what actually occurs during a school/sports exam, you might not be able to choose these codes for your provider’s services if all the provider does is a school or sports physical. If a provider is going to use these codes, then he must satisfy the criteria for the code during the encounter.

If, however, the visit does not meet the criteria for a preventive medicine visit and the notes do not document a comprehensive history and examination, you might report either an appropriate level office or other outpatient E/M visit code (99201-99204 for new patients and 99212-99214 for established patients) or unlisted-procedure code 99499 (Unlisted evaluation and management service). Check with your payer to see if either of these is something you can code for sport/camp/school physicals.

Remember: All of the aforementioned coding options are potential solutions for your school/sports physicals. Before choosing any of the options listed above, check with the payer to ensure you are coding according to its conventions.

If you cannot find a way to rightfully code for the physical, you’ll have to bill the patient for the service.