Pediatric Coding Alert

Before lack of coverage for sports physicals pushes you into using creative coding strategies, get back to basics with the AMAs recommendations on using preventive medicine services for visits that include a comprehensive history and exam and office visits for E/M services that dont.

Because many managed-care organizations cover preventive medicine services (99381-99397) once a year for young children and every other year for older children, schools that require exams more often present a reimbursement dilemma: How can your pediatrician recoup her services in the absence of coverage?

Faced with this question, you may look for alternative coding methods, but remember that the coverage or non-coverage of a service should not impact proper CPT coding, says Gregory L. Schnitzer, RN, CCS, CCS-P, CPC, CPC-H, RCC, CHC, manager of coding compliance and quality assurance for CodeRyte in Bethesda, Md. On three separate occasions, the AMA has officially addressed how to report sports physicals based on the elements that the physician performs. Schnitzer recommends that coders follow these guidelines regardless of coverage.

1. Use 99381-99397 When Exam Is Comprehensive

 
During a visit for a sports physical, if your pediatrician performs a comprehensive history and examination, you should report the age-appropriate code from the preventive medicine series, according to July 1996 and August 1997 CPT Assistant. Report 99383-99385 (Initial comprehensive preventive medicine evaluation and management of an individual ... new patient) or 99393-99395 (Periodic ... established patient), depending on the patients status and age. Make sure to link all comprehensive preventive examinations (CPEs) to the diagnosis code for a child (V20.2, Routine infant or child health check) or adult (V70.0, Routine general medical examination at a healthcare facility) well visit.
 
To increase sports exam coverage, try to schedule the sports physical during the childs preventive medicine service. If a patient has not had his or her annual physical, the pediatrician should perform the full physical at the time the parent requests the sports physical, says Jaime Darling, CPC, certified coder for Graybill Medical Group, which has four pediatricians, in Escondido, Calif.

For instance, a 17-year-old girl requires medical clearance to participate in varsity cheerleading. When the mother calls to make the appointment, the scheduler notices that the child is due for a preventive medicine service and books a full well visit. The pediatrician performs the CPE and completes the sports form. You should report the visit with 99394 (Periodic comprehensive preventive medicine re-evaluation and management of an individual ..., adolescent [age 12 through 17 years]) linked to V20.2

Sports forms, especially for high-school children, are often so extensive that they require a CPE (99383-99385, 99393-99395). Many coding experts think the preventive medicine service codes better reflect the reason for a sports physical to prevent injuries from occurring, rather than to treat a current illness.

2. Absent Comprehensive Elements, Bill a Sick Visit

Regardless of these arguments, if the pediatrician performs less than an age- and gender-appropriate comprehensive history and exam, report a problem-focused office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ), according to CPT. If the physician performs a problem-focused, expanded problem-focused or detailed history and examination, then report the appropriate-level office or other outpatient evaluation and management visit code, states the 1999 edition of The CPT Companion book, as well as the July 1996 and August 1997 CPT Assistant.

Suppose a 9-year-old-boy who had a well exam nine months ago requires a sports exam to clear him for the fall soccer season. The pediatrician performs an expanded problem-focused history and examination. You should bill for the work done, Darling says. In this case, assign 99213 with the sports physicals diagnosis (V70.3, Other medical examination for administrative purposes).

Because virtually all insurance companies do not pay for sports physicals, you should collect payment for the visit in cash up-front, Darling says. Before billing the parents, check your contract to make sure this is allowed. If the plan does not cover sports physicals, charging the parents is appropriate.

 
Do not attempt to get around V70.3 noncoverage by reporting 99383-99385-52 or 99393-99395-52 (Reduced services) with V20.2 or V70.0, Schnitzer warns. Not only will assigning the well-visit diagnosis use up the childs annual checkup, but CPT admonishes against this alternative billing method. 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, the appropriate office or other outpatient E/M service code should be reported based upon the key components that are met (i.e., history, physical exam, medical decision-making).