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Physical for new medical insurance coverage

  1. Default Physical for new medical insurance coverage
    Medical Coding Books
    We have had several patients in our office requesting a "routine" physical for their insurance coverage. They state all they need is proof of a physical exam to obtain coverage and insist their insurance will pay. We dont normally do routine physicals, only basic self-pay only ones---for sports, school.... I know this cant be coded as a reg office visit, but it really isn't preventive either (no comprehensive history or exam is done). Is anyone else seeing these? If so, are you doing a full preventive service & billing that way, or self-pay, or am I missing another option?


  2. #2
    This is a common issue that all offices struggle with. I'm not sure if there is any "right" way to do it but I have worked for two large multi speciality hospital and health networks who both took the same stand after much research and compliance review.

    You have options. If the person has not had a complete "Preventive exam" and they would like one then the Physician can perfrom you can report the appropriate preventive code "9938x-9939x and complete the forms based on that documented exam. I would stress that the Provider needs to do everything they would do for a complete preventive exam based on pateint's age including age appropriate history, exam and risk factor reduction/anticipitory guideance.

    The other option is if they have had a 'complete' well exam within the past 6 months to a year you can complete the paperwork based on that exam and charge a "forms fee" to the patient (recommend office have a policy for how much you charge for forms outside of visit).

    Finally, if the patient just wants to come in and have the visit to complete the paperwork you can report the unlisted E/M code 99499 (or 99429 screening unlisted service) with the appropriate V70.3 or V70.5 dx. code. Most carriers will not pay for this because it is considered a "madated exam" and is a typical benefit exclusion so the patient should be aware that they will have to pay out of pocket. You can set a reduced fee for this service to make it feasable for patient's who need a "less than comprehensive preventive serivce".

    IF this is for life insurance there is the code 99450 for basic life and/or disability evaluation - but again this would most likely be patient responsibility.

    The above info can be applied to all kinds of "limited" physicals such as sports, camp, DOT, adoption, school, employment, foriegn travel, etc.

    Others may say to bill an E/M visit with the V70.5 or V70.3 but the 99499 is the way the two large organizations I have been with have decided.

    Hope that helps! (sorry for any typos - did not spell check)

    Christina Musser, CPC

  3. Default
    Thank you, that is what I thought, but it is nice not to be alone....

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