Primary Care Coding Alert

Question: Our physicians are starting to see a lot of school-aged patients who need Spring sports physicals. Which codes are required to properly report them?

Washington Subscriber

Answer: Use the following codes for children aged five through 17. These codes will usually cover all the bases for school, sports, or work physicals, if the provider thoroughly documents the visit, including growth and developmental milestones for younger patients and all the other age- and gender-appropriate components required.

• 99383/99393 (Initial/Periodic comprehensive preventive medicine evaluation/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 new/established patient… late childhood (age 5 through 11 years))
• 99384/99394 (… adolescent (age 12 through 17 years))

Remember: Most payers only pay for one preventive physical exam per year. This can get tricky when a patient has already had their yearly physical but now needs something for school sports, but if the patient had a preventive medicine exam within the past couple of months, you might be able to use the information gleaned from that visit to fill out a school/sports form. It should also be noted that if the provider deems the recent preventive exam current enough, just filling out the form does not warrant an evaluation and management (E/M) service code.

Note: Remember to include Z02.5 (Encounter for examination for participation in sport).

Coding alert: Look to payer guidelines for age-specific diagnosis coding rules. For example, Z00.12- (Encounter for routine child health examination) or Z00.0- (Encounter for general adult medical examination) are subject to age-specific Medicare Code Edits (MCEs), which instruct you that Medicare will reimburse for a Z00.12- code only for patients from the age of 0 through 17 years old (which it defines as “pediatric”), and a Z00.0- code for patients 15 through 124 years of age (which it labels “adult”). (Source: www.cms.gov/medicare/coding/icd10/downloads/icd10_ mce27_user_manual.pdf)