Primary Care Coding Alert

Question: Our FP performs school and college physicals on a regular basis. I did not come across any codes that are specific for this service. I am wondering, can I report a regular E/M code or a preventive medicine code to report these services?

Nebraska Subscriber

Answer: As you have correctly mentioned, there are no specific codes that you can report when your FP performs a school or a college physical. The code you report for the service will likely depend on the extent and nature of the service.

If the physician performs a comprehensive history and examination, then you should consider reporting the age appropriate preventive medicine codes such as 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 or 99393-99395(Periodic comprehensive preventive medicine reevaluation and management of an individual ...) for established patients to report a school or a college physical. Indeed, many physicians will provide a school or college physical as part of a patient’s regular annual physical visit, since many payers only cover one preventive medicine visit every 12 months. So, if the patient has not had an annual wellness visit in the previous 12 months, you can consider scheduling the physical and the well-care visit simultaneously and cover both the services during the same visit.

You cannot use these codes as a school or college physical if the service is not as comprehensive and does not include all the components that are needed to support the level of service required to report preventive medicine codes. Also, school or college physicals do not necessarily include the counseling and anticipatory guidance components of a regular well-care visit. In this case, consider reporting the appropriate level office or other outpatient evaluation and management (E/M) visit code. The potential problem in doing so is that such E/M visit codes are typically considered to be problem-oriented while the school or college physical is not, as indicated by the diagnosis commonly used with such physicals, V70.3 (Other medical examination for administrative purposes). A payer may deny a claim for a problem-oriented E/M service with V70.3 or similar diagnosis attached. 

So, if the patient has had a regular well-care visit already and the payer will not allow you to report an E/M code for a college physical, you may have to look at charging the patient for the visit, since, as noted, most payers only cover one well-care visit per year.In this case, you should keep the patient informed that the physical is not a covered service by itself, and the patient will have to pay for the service.

Reimbursement tip: If you are not sure if the service will be covered by the insurance payer, it is best to let the patient know that the visit might not be covered by his/ her insurance. Ask them to pay up front, and inform them that they would be reimbursed back if the payer covers the visit.