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Head Start/Sport Physical

  1. Default Head Start/Sport Physical
    Medical Coding Books
    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?
    Last edited by amadison; 03-05-2010 at 09:42 AM. Reason: Change Title

  2. #2
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    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!!

  3. Default
    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?

  4. #4
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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

  5. #5
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    Quote Originally Posted by amadison View Post
    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?
    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.

  6. #6
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    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.

  7. #7
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    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...
    Last edited by RebeccaWoodward*; 03-08-2010 at 12:06 PM. Reason: SPELLING

  8. #8
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    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).
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  9. #9
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    Quote Originally Posted by dballard2004 View Post
    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?
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC
    PMCC Licensed Instructor
    Kansas City, MO Chapter
    President, 2018
    Vice President, 2017
    Member Development Officer 2016
    Harrisonville, MO Chapter President - 2013
    ICD-10 Education Coordinator- 2012
    Chapter President - 2011
    President Elect - 2010

  10. #10
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    Quote Originally Posted by LINDALOUV View Post
    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?
    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."

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