Primary Care Coding Alert

Question: A patient came to our FP for a school physical as he was required by admission rules to have a physical within the past six months. However, the patient had already had an annual physical about eight months back. Can we bill two physicals within the span mentioned? If so, what codes should I report for the visit?

New York Subscriber

Answer: Most payers only allow you to report an annual physical (such as 99395, Periodic comprehensive preventive medicine reevaluation 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, established patient; 18-39 years) only once in the span of an year (i.e. 12 months).

Since only eight months have elapsed since the patient had his previous annual physical, you will probably not be allowed to report the school physical with the same CPT® code to the patient’s insurance. For this reason, many practices have adopted the practice of trying to schedule a school physical at the same time as the annual physical, so both the services can be clubbed together and reported with an age appropriate preventive medicine code.

As this cannot be done in your case, you will now have to look at whether or not the particular payer will allow you to report a problem-oriented E/M code (such as 99212, Office or other outpatient visit for the evaluation and management of an established patient…) to cover the visit. You will have to use an appropriate diagnosis code such as V70.3 (Other general medical examination for administrative purposes).

However, you should remember that some payers will not cover the use of a problem-oriented E/M code for a school physical. Since you won’t have a chief complaint or medical diagnosis and the encounter is not problem-oriented (as reflected by the diagnosis of V70.3), some payers may consider submitting these codes to be improper.

If the payer does not provide you the option of using either a preventive medicine E/M code or a problem-oriented E/M code to report a school physical, then you are left with only a couple of other options. One is to try using the unlisted E/M code, 99499 (Unlisted evaluation and management service).Alternatively, if your contract with the payer permits it, you can charge the patient directly for the visit. In that case, you should let the patient know up front that the visit will not be covered by the payer and he will have to pay for the visit out of pocket.