Eli's Rehab Report

Published on Wed May 04, 2016 PDF

Question: A fellow coder recently suggested reporting codes 97005 and 97006 for sports physicals. Are these codes really applicable, and will we be reimbursed if we use them?

Answer: One crucial element of 97005 (Athletic training evaluation) and 97006 (Athletic training reevaluation) renders these codes inapplicable to sports physicals — these codes represent problem-oriented services, such as, recognition and evaluation of an athletic injury, formulation of a treatment plan/intervention, and educational training for a specific injury.

To report a sports physical, a non-problem-oriented evaluation of a patient for certification for involvement in organized sports, you could choose an age-appropriate preventive medicine code. To use the preventive medicine series of codes, 99381-99397, the physician must perform and document a comprehensive (age- and gender-appropriate) history and examination.

For many sports physicals, the history and exam performed is not synonymous with a well-child exam performed by their primary-care provider. If the physician does not have documentation of a full comprehensive history and examination, you should report the appropriate-level office visit (E/M service) or other outpatient E/M visit code.

Link the most appropriate CPT^® code to diagnosis code Z02.89 — General medical examination; other medical examination for administrative purposes and Z02.5 — Encounter for examination for participation in sports.

You might be tempted to report a preventive medicine code such as 99383-99385 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/diagnostic procedures, new patient ...) for new patients or 99393-99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual ...) for established patients. However, sports physicals by themselves do not always rise to this level of service.

“For instance, sports physicals do not always necessitate the kind of comprehensive, age- and gender-appropriate history and examination associated with preventive medicine visits,” points out Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. Likewise, sport physicals do not necessarily include the counseling and anticipatory guidance components of a regular well-care visit.

Note: Many insurance companies may not reimburse for an E/M visit code linked to Z02.89. You should check with the payer to see if a sports physical is a covered benefit or if the visit should be the patient’s responsibility.