Face Off Against Widespread Sports Physical Coding Challenges

By Author: James Smith
Total Articles: 3
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Hint: Gathering upfront pay and watching E/Ms certainly make a difference


Children require physicals to take part in their favorite sports year round. However the demand can grow with the warm weather approaching. Preferably, the need for sports physicals should provide the opportunity to offer complete age-appropriate medical exams following the American Academy of Pediatrician's Bright Future Guidelines. However if your practice runs into reimbursement obstacles for full-scale physicals, follow our expert's tips to code right and still remain in the game.


Tacking coverage issues


Selecting the diagnosis code for sports physical is quite easy. You will report V70.3 (Other medical examination for administrative purposes).


Going for the best CPT code for a sports physical is a bit more complex. "I struggle with this as the services rendered is preventive, but does not meet the criteria (according to me) of the preventive medicine E/M codes," states JoAnne M. Wolf, ...
... RHIT, CPC, coding manager for Children's Physician Network in Minneapolis, Minn.


The reason: In most cases, a child coming for a sports physical does not have a chief complaint, so it seems inappropriate to code from the 9920-99215 range (codes for an office or other outpatient visit for the E&M of a new or established patient), points out Wolf.


Even though the preventive medicine E/M codes 99381-99397 (codes for initial or periodic comprehensive preventive medicine evaluation and management of an individual) satisfy the requirements for sports physicals, they also seem inappropriate. When the patient requests only a sports physical, the service you provide does not meet the codes' comprehensive nature.


"Physicals are a tough topic to discuss as some insurances won't cover them at all and some will cover them in various ways," Susie Stokes, CMC, CMOM, practice manager of Morgan Pediatric Group in Smyrna, Tenn says.


Common guidelines cover:


One each calendar year
One each year following the patient's birthday
One after a year and one day after the last physical


Other complications can crop up owing to the sports organization's rules. For instance, Stokes says most school sports in her area need a physical after May 1 of the present year. If the kid had a physical before May 1, and the sports league requires it after May 1, the parents are in a tight spot. They do not want to pay for another physical and the insurance provider won't pay.


In this case we go ahead and sign the form and date it the date of the physical with all the information," says Stokes. "Then if the association wants another physical, the school explains it to the parents so that we do not appear as the bad guys."


Good practice: Your first step should be to inquire patients to pay cash for the sports physical (particularly those with insurance you know does not cover the service). If the parent insists that insurance will cover the exam, see to it that the family that your practice will file a claim and reimburse the parent if insurance does pay.


Pitch preventive visit instead


If the patient's insurance covers a yearly preventive medicine service, you can offer that service in lieu of the sports physical and maximize the patient's advantages - plus keep your coding clean. This approach is supported by AAP recommendations.


According to Wolf, "Many of our clinics will carry out the full preventive medicine service at the time the patient presents for a sports physical." "Adolescents and teens are age groups that don't tend to come in regularly for their preventive services; as such our clinics try to take advantage and get the complete well visit done at that time."


New tactic: Your coding will change if you are able to provide a preventive care visit. Select the best code from 99381-99385 (Initial comprehensive preventive medicine evaluation and management of an individual ) based on the patient's age for a new patient or from 99391-99395 ( Periodic comprehensive preventive medicine reevaluation and management of an individual) based on the patient's age for an established patient.


For the preventive examination's diagnosis, you also have two choices. Choose V20.2 (Routine infant or child health check) for children up to the age of 18 years. For those who have crossed 18 years of age, shift to V70.0 (Routine general medical examination at a health care facility).


Catch extra services


With these patients, watch for additional coding opportunities as a sports physical might extend to include other services.


If the pediatrician provides a problem-oriented E/M service for a separate, noteworthy problem in addition to the sports physical or preventive medicine service, you can even code for it.


What's next: As soon as you choose the right E/M codes, go for modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to that E/M code and include documentation supporting the care as an added service.


You should be able to connect the E/M code to a specific diagnosis for the problem addressed like 493.00 (Extrinsic asthma; unspecified) for asthma that is well controlled with medication or 314.01 Attention deficit disorder; with hyperactivity) for ADHD managed with stimulant medications.


Head off the competition


Yet another challenge with sports physicals lies in the ever-growing number of "retail" clinics that offer quicker testing and less expensive mistakes. However, Stokes and Wolf agree that convenience does not equal quality.


According to Stokes, "We do not do what people call the quick sports physical." "We realize the parents want something quickly, but we are clearing these kids to play sports and we have to take the right amount of time to ensure they are in good health to play."


Wolf adds, "Many of the primary care pediatric clinics in our network have countered the retail clinics by offering ‘walk-in' services during regular clinic hours."