Primary Care Coding Alert

Question: Most of our insurance companies won't pay for a sports physical after the patient has already had a yearly physical. Once the parents learn they'll have to pay, they want to count their child's general physical in the sports physical's place. Are there certain services other than filling out paperwork (such as an EKG) that distinguish a sports physical? We'd also like to establish a fixed amount to charge for physicals that insurance won't cover. Do you have any advice?

Answer: Sports physicals are distinguished from yearly preventive medicine physicals both in their scope and their focus. A sports physical lacks many of the elements of an age- and genderappropriate comprehensive history, examination, counseling and anticipatory guidance, which are otherwise required elements of an annual preventive medicine visit (i.e., yearly physical) represented by codes 99383-99385 and 99393-99395. Also, a sports physical is focused on determining whether the patient is physically fit to play the sport in question, whereas a yearly physical is more broadly focused on the patient's general health, prevention, etc.

Few insurance companies pay for sports physicals, but don't lose hope yet.

Begin by confirming your state's regulations. For example, Kentucky guidelines state that a physical done within the last 12 months is sufficient (although physician offices might have to fill out another form for the next school year, depending on the exact date of the physical).

Educate the parents. Make sure they understand that the separate physicals are the state's requirement, not yours, when that is the case. If you do conduct a physical, charge a fee that will cover the cost to your practice of providing the service. This includes the physician's time, any clinical and non-clinical staff time involved, and the cost of medical and other supplies associated with the physical. Specific fees for the service can vary by practice. Ask that the parents pay your fee up front, unless you know that their insurance will cover the visit.

If you simply help complete sports physical forms (e.g., based on the results of the patient's previous yearly physical), you will need to decide whether or not to charge for this service. Many physician offices don't charge for completing such paperwork. However, it does represent a time and expense to your practice, so charging a fee for it is not unreasonable. If your practice does charge a fee for completing such paperwork, then make that policy known up front, so there is no surprise to the patient or parents after the fact.

An EKG isn't necessary for every child having a sports physical, unless they answer "yes" to questions about palpitations, family history of sudden cardiac death, or related issues. Some physicians recommend asking these questions of every middle and high school student even if they don't plan to participate in sports. You never know when they might change their minds, and asking the questions up front will give you some baseline information.