When billing for a Head Start exam or sports physical, using DX V70.3, can you bill an E/M code (99213, 99214) instead of a preventative code? Or do you have to bill them as preventative?
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Wiki Head Start/Sport Physical
- Thread starter amadison
- Start date
We bill a preventive code for head start phyicals, as we count it as their child physical but coded as V70.3. Most insurance companies will not pay for a sports physical's so I would check with the insurance to see if they will pay. We have a set rate of $25.00 for sports physicals and they are not sent to the insurance unless the patient sends in a claim. I hope this helps!!
We have a physician who wants to bill E/M and not preventative. He wants to bill 99214 because he does a detailed history and physical exam, including full social hx, meds, allergies, past medical, past surgical, and a comprehensive exam fpr the head start or sports physical. Is this legitimate and does anyone else bill this way?
dballard2004
True Blue
Per CPT® Assistant, sports physicals should only be reported with a preventative medicine code if the provider performs a comprehensive history and exam. If the provider performs a brief, detailed, or extended history and exam, report the appropriate office/outpatient E/M code (99201-99215)
RebeccaWoodward*
True Blue
In my experience, I find it hard to get a detailed/comprehensive history for preventatives using non-preventative codes. The HPI is normally an issue since the patient doesn't have a problematic complaint...normally.
You shouldn't bill a non-preventative code (i.e. 99214) for any type of preventative service...whats the chief complaint? Where's the HPI?
Most schools will accept the preventative service (well child) if done within the last year...if they havent had one, why not schedule them for their well child visit and bill their insurance, then use that exam to complete their forms?
Otherwise, there should be a policy in place like KKNOX mentioned, where you charge a flat fee for this non-covered service. That's our policy here.
Most schools will accept the preventative service (well child) if done within the last year...if they havent had one, why not schedule them for their well child visit and bill their insurance, then use that exam to complete their forms?
Otherwise, there should be a policy in place like KKNOX mentioned, where you charge a flat fee for this non-covered service. That's our policy here.
RebeccaWoodward*
True Blue
Exactly my point; however, there are a couple of CPT Assistants that instruct a little differently.
CPT Assistant '97
What code should I use to report a "sports physical" or a "school physical?"
If the physician performs a comprehensive history and examination, then you should report the age appropriate code from the preventive medicine series. 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.
I'm not an advocate of this method but one could argue their point since there is not a true CPT code designated for a school/sports exam. I've seen various methods for reporting these...
CPT Assistant '97
What code should I use to report a "sports physical" or a "school physical?"
If the physician performs a comprehensive history and examination, then you should report the age appropriate code from the preventive medicine series. 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.
I'm not an advocate of this method but one could argue their point since there is not a true CPT code designated for a school/sports exam. I've seen various methods for reporting these...
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dballard2004
True Blue
I see where you are coming from here, but CPT Assistant advises that unless the sports physicial is truly comprehensive in nature, you report an Office/Outpatient E/M code (99201-99215).
Understood, but does CPT Assistant advise how you'd get a C/C and HPI? I'm pretty sure in the CPT book it says these are required for a level of history which is one of the three key components. What am I missing?
RebeccaWoodward*
True Blue
My other concern is medical necessity. If the child needs a school/sports PE, what is being documented by the provider to support the "detailed/Comp" HPI/History? I know I have a Medicare mindset but I tend to think that most carriers would agree with Medicare's guideline...
"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported."
kewing
Networker
What about modifiers?
What about the use of the -52 modifier (reduced services) attached to a preventative exam code for these types of physicals when the provider performs less than a comprehensive history and exam?
Also, as I understand it, the choice of diagnosis code is ultimately controlled by the reason the patient is being seen. If the c/c or reason for visit is identified as a third party physical, should we not be using V70.3 even if the visit qualifies as a routine health check?
What about the use of the -52 modifier (reduced services) attached to a preventative exam code for these types of physicals when the provider performs less than a comprehensive history and exam?
Also, as I understand it, the choice of diagnosis code is ultimately controlled by the reason the patient is being seen. If the c/c or reason for visit is identified as a third party physical, should we not be using V70.3 even if the visit qualifies as a routine health check?