Primary Care Coding Alert

Question: A patient comes in for a school physical, but the patient's insurance does not cover a preventive physical.
 
How should I code the physical? Because the family physician did not perform a comprehensive physical, we do not want to charge the patient our normal charge ($130) for that service. Are we allowed to charge the patient a lesser fee ($50) and not submit the claim to the insurance company?

Pennsylvania Subscriber

Answer: First, remember that coding and billing are two distinct things. You must code the service appropriately, regardless of payment and/or insurance coverage.
 
If the FP performed less than a comprehensive preventive medicine service, you should code the visit as an office visit (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...). Watch out: The fact that the physician doesn't perform a comprehensive examination doesn't rule out a preventive medicine service, such as 99393 (Periodic comprehensive preventive medicine reevaluation and management of an individual -).
 
Codes 99381-99397 require a comprehensive age- and gender-appropriate history/exam, which -is NOT synonymous with the -comprehensive- examination required in Evaluation and Management codes 99201-99350,- according to CPT's preventive medicine services- introductory notes.
 
Regardless of whether the service qualifies as 99381-99397 or 99201-99215, you should use the school admission medical examination V code: V70.3 (Other medical examination for administrative purposes), which includes -General medical examination for: school admission,- as well as -camp- and -sports competition.-
 
Payment: The insurer may cover 99381-99397 if  the patient has not met his yearly well care benefits. Payment for 99201-99205 with V70.3 may prove harder to come by because the CPT code is problem-oriented, whereas the ICD-9 code is not.
 
Key: If the insurer considers the service -noncovered,- you may charge the patient a set -school physical- fee that may be less than your preventive medicine service rate.
 
Don't append modifier 52 (Reduced services) to 99381-99397 to indicate a school physical that fails to  meet a preventive medicine service's -comprehensive- nature. Some practices have used this strategy and charge a lesser fee. But using modifier 52 on a preventive medicine service is not appropriate coding from a CPT perspective.