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Sports VS Wellness physical

  1. #1
    Default Sports VS Wellness physical
    Medical Coding Books
    We had a patient that came in for a "sports physical" and it was billed with DX V70.3 and our sports physical code (99213SP). The documentation stated "patient here today for a sports physical" and there is the vision test and then the rest says "see sports form for remaining information". The mother is upset because we didn't bill this as a yearly wellness physical. She says that her insurance told her that all we have to do is recode the visit(99394) and use a different dx(V70.0 or V20.2) and have the dr ammend their notes and then it will be paid. CAN WE DO THAT?!?! I told the mother that it is my understanding that this would be committing insurance fraud if we were to do this. Of course the difference between a yearly wellness exam and a sports physical is about as clear as mud to me so it is hard to fully get the patient to understand why we are billing it as such. Can someone please help clarify this for me?

    THANKS A TON!!
    Angie

  2. #2
    Default
    Hoping someone else has a thought about this?

    My question is similar:

    Wouldn't it be proper to bill a Well Visit for a Sports PE? I am sending a query back to the provider to find out if she feels the visit was comprehensive or if I need to bill a 99395-52?

    Anybody familiar with sports exams vs well exams?
    Heidi Thompson, CPC

  3. #3
    Location
    Overland Park, KS
    Posts
    1,166
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    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)
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  4. #4
    Default
    Okay, thanks.

    I also just read on another thread that -52 is never used with E/M codes. Another surprise for me. Luckily, I don't see it very often.

    I'm just curious how the insurances handle a 99213 with V70.3? They don't question the lack of a problem?
    Last edited by hthompson; 01-14-2010 at 10:42 AM.
    Heidi Thompson, CPC

  5. #5
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    I strongly disagree with using anything other than preventive codes for sports physicals. If you have no complaint you can't use a problem visit (99201-99215).

    It is very possible to do a true yearly physical along with the sports physical, usually the only addition to the physical is they are filling out a form for the patient in order for them to participate in sports.

    If they are not doing a true yearly exam the only appropriate code would be 99429 the unlisted preventive medicince service, which of course is not covered by insurances (well not any I know of that is). You need a policy in place to deal with these services as they should be paid for in advance and the patients made aware insurance will not cover them.

    Laura, CPC, CPMA, CEMC

  6. #6
    Location
    Overland Park, KS
    Posts
    1,166
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    Laura,

    I understand what you saying, but this is how CPT Assistant says to code these types of visits.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  7. #7
    Default
    Quote Originally Posted by katmryn78 View Post
    I strongly disagree with using anything other than preventive codes for sports physicals. If you have no complaint you can't use a problem visit (99201-99215).

    If they are not doing a true yearly exam the only appropriate code would be 99429 the unlisted preventive medicince service, which of course is not covered by insurances (well not any I know of that is).
    Laura, CPC, CPMA, CEMC
    I would be interested in where you found this information and something to support it.

    Thanks!!
    Heidi Thompson, CPC

  8. #8
    Location
    Overland Park, KS
    Posts
    1,166
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    CPT Assistant, July 1996, page 10
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  9. #9
    Default
    I was referring to Laura's citation of using 99429. Thanks. I'll look that up and print it too. I need back up documentation for the providers.
    Heidi Thompson, CPC

  10. #10
    Default
    Heidi,

    The reason I go to the unlisted is based on Medicaid. Medicaid has very specific requirements in order to bill the defined preventive codes 99381-99397. If those are not met, which in basic sports physicals they usually aren't, you are commiting fraud by billing Medicaid. With the unlisted code there are no requirements because it is not covered.

    Hope that clears it up. I have dealt with this for several years and sometimes forget to explain that part of it.

    Laura, CPC, CPMA, CEMC

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