Primary Care Coding Alert

Question: When my family physician (FP) performs a sports exam and performs a brief history only, may I report a preventive medicine service appended with modifier -52?

Wyoming Subscriber

Answer: No, CPT does not consider it appropriate to append modifier -52 (Reduced services) to a preventive medicine service (99381-99397). "It would not be appropriate to append modifier -52 to a preventive medicine E/M service code when only a brief history and examination is performed," states CPT Information Services, dated April 13, 2001. Instead, you should report the appropriate office or other outpatient E/M service code based on the key components - history, physical exam, medical decision-making - that the physician performs.
 
For instance, suppose the FP performs an age- and gender-appropriate comprehensive history and examination. In this case, you should report the age-appropriate code from among the preventive medicine services, such as 99394 (Periodic comprehensive preventive medicine re-evaluation and management of an individual ...; adolescent [age 12 through 17 years]), according to CPT Assistant, August 1997. On the other hand, if the physician performs a problem-focused, expanded problem-focused or detailed history and examination, CPT indicates that you should report the appropriate-level office visit or other outpatient E/M code.
 
Because some sports exams are not as detailed as annual exams, the FP may perform an expanded problem-focused history and examination for an established patient. In this case, you should assign the E/M code based on the components met. For an established patient expanded problem-focused history and examination, you should report 99213 (Office or other outpatient visit for the E/M of an established patient ...).