Pediatric Coding Alert

Are you ready for the back-to-school crew?

School and athletic physicals are an annual rite of passage for many of your school- and college-bound patients. But are you handling them correctly?

To help you and your pediatrician foster great relationships with your patients while receiving the maximum amount of reimbursement your practice is entitled to, we’ve assembled answers to four frequently asked questions about the best way you can provide this service to your patients before the school year begins.

Can the Results of a Preventive Medicine Service be Used for Physicals?

Yes. In fact, this is the best way to perform this service for your patient, as the patient will not have to pay out of pocket for the service if their insurance covers the cost of evaluation and management (E/M) services 99381-99385/99391-99395 (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 …).

Such services cover all the bases for school and sports physicals, including documenting a patient’s physical growth, marking developmental milestones for younger patients, and determining the psychological health of older patients. They also provide a chance to update the patient’s vaccination status, which is a key requirement for most school registrations. And the health history and physical exam component of the services are comprehensive enough, and can be tailored to, athletic activities. (For a more comprehensive list of services associated with 99381-99385/99391-99395, consult the article “Follow These 5 Recommendations for Preventive Medicine Documentation Success” in Pediatric Coding Alert Volume 24 Number 2).

But this requires your practice to work with your patient to schedule preventive medicine services around the peak times for the beginning of the school year or start of team sports seasons.

What if We Don’t Use a Preventive Service for a School Physical?

One option you have here would be to use 99499 (Unlisted evaluation and management service). The problem is that few, if any, insurances will reimburse for the code, and the patient may be left to foot the bill. That means “you should alert the patient to this potential responsibility before the patient presents to the office,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Under these circumstances, your practice should collect on this service at the time of service. “Then, your practice can refund if the patient’s insurance pays the 99499,” Moore advises.

Another option would be to have a “sports physical clinic,” which can be done in the evening, weekends or even early mornings especially in the summer when illnesses are typically not as heavy. Again, this would be another out-of-pocket service and would not be filed to insurance. This is a great way to get your patients to your office instead of to pharmacies or urgent care facilities that do these physicals as well.

But remember: these services do not take the place of the preventive physical and only serve for the sports physical, allowing the practice to earn extra revenue.

What not to do: You should never use the problem-oriented E/M codes 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/ established patient …) for the simple reason that a school physical is not intended to evaluate or manage a medical problem. And 97169-97171 (Athletic training evaluation ...) and 97172 (Re-evaluation of athletic training established plan of care ....) are also off the table as they are intended for use by athletic trainers to evaluate and manage sports-related injuries.

What Is the Best ICD-10 Code to Use When Documenting a Physical?

That depends on the purpose of the exam, and whether it reveals any abnormal findings. You should “use the code(s) that most accurately reflect the reason for the encounter,” and you can also “report more than one ‘encounter for’ code when appropriate,” according to the American Academy of Pediatrics (AAP) (Source: www.aappublications.org/content/36/7/28.1).