Pediatric Coding Alert

Now that school has begun, pediatricians will be performing sports exams, which are generally required for sports in middle, junior and high schools. The school wants to avoid liability by obtaining medical clearance but doesnt pay the pediatrician to provide a clean bill of health. The childs health insurance may pay for the service, however, depending on how the claim is coded. The dilemma for pediatricians is that although there is a diagnosis code for sports physicals (V70.3, other examination for administrative purposes), there is no CPT code. Depending on the situation, there are several methods to increase chances that insurance will cover the visit. Concurrent Preventive Medicine Exams  Incorporate the sports physical into a prescheduled preventive medicine exam. Although this will not warrant additional payment, the visit will at least be paid. Report 99383-99385 (initial preventive medicine evaluation and management of an individual new patient) or 99393-99395 ( established patient), depending on the patients status and age.
 
For example, an 11-year-old boy requires medical clearance to play varsity soccer. When the mother calls to make an appointment, the scheduler notices that the boy is due for a preventive medicine service and books a full well visit. The doctor performs the physical and completes the sports form. Code the visit 99393 (... late childhood [age 5 through 11 years]), using the well-visit diagnosis (V20.2 , routine infant or child health check). Extra Preventive Medicine Exam Because of the work involved in a sports exam, in some cases pediatricians may bill a preventive medicine visit even if the child is not due for a checkup.
 
For example, a 14-year-old girl plans to play basketball. The pediatrician saw the girl for a full well visit 10 months ago but feels that the information from that encounter is current enough to qualify for the sports physical. He or she performs the requirements of the sports physical -- a superficial complete exam with emphasis on the musculoskeletal system -- and codes 99394 (... adolescent [age 12 through 17 year]).
 
Many insurers will cover only one well visit per year. If the child has already had a well visit within 12 months, payment for the sports exam may be rejected. Recent Preventive Medicine Exam This scenario entails copying the information from the chart of a recent well visit onto the sports physical form. If the well visit occurred recently (i.e., within one calendar year) and there are no ongoing medical problems, most pediatricians would feel comfortable doing this, says Richard H. Tuck, MD, FAAP, founding chairman of the AAP coding and reimbursement committee and a practicing pediatrician in Zanesville, Ohio. This service would not warrant an extra fee, although there would be the extra office work of [...]