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Pediatric Coding Alert

Using 99381-99397-52 for Sports Exams? CPT Rules May Surprise You

- Published on Tue, Jul 01, 2003
Before lack of coverage for sports physicals pushes you into using creative coding strategies, get back to basics with the AMAs recommendations on using preventive medicine services for visits that include a comprehensive history and exam and office visits for E/M services that dont.

Because many managed-care organizations cover preventive medicine services (99381-99397) once a year for young children and every other year for older children, schools that require exams more often present a reimbursement dilemma: How can your pediatrician recoup her services in the absence of coverage?

Faced with this question, you may look for alternative coding methods, but remember that the coverage or non-coverage of a service should not impact proper CPT coding, says Gregory L. Schnitzer, RN, CCS, CCS-P, CPC, CPC-H, RCC, CHC, manager of coding compliance and quality assurance for CodeRyte in Bethesda, Md. On three separate occasions, the AMA has officially addressed how to report sports physicals based on the elements that the physician performs. Schnitzer recommends that coders follow these guidelines regardless of coverage.
1. Use 99381-99397 When Exam Is Comprehensive  
During a visit for a sports physical, if your pediatrician performs a comprehensive history and examination, you should report the age-appropriate code from the preventive medicine series, according to July 1996 and August 1997 CPT Assistant. Report 99383-99385 (Initial comprehensive preventive medicine evaluation and management of an individual ... new patient) or 99393-99395 (Periodic ... established patient), depending on the patients status and age. Make sure to link all comprehensive preventive examinations (CPEs) to the diagnosis code for a child (V20.2, Routine infant or child health check) or adult (V70.0, Routine general medical examination at a healthcare facility) well visit.
To increase sports exam coverage, try to schedule the sports physical during the childs preventive medicine service. If a patient has not had his or her annual physical, the pediatrician should perform the full physical at the time the parent requests the sports physical, says Jaime Darling, CPC, certified coder for Graybill Medical Group, which has four pediatricians, in Escondido, Calif.

For instance, a 17-year-old girl requires medical clearance to participate in varsity cheerleading. When the mother calls to make the appointment, the scheduler notices that the child is due for a preventive medicine service and books a full well visit. The pediatrician performs the CPE and completes the sports form. You should report the visit with 99394 (Periodic comprehensive preventive medicine re-evaluation and management of an individual ..., adolescent [age 12 through 17 years]) linked to V20.2

Sports forms, especially for high-school children, are often so extensive that they require a CPE (99383-99385, 99393-99395). Many coding experts think the preventive medicine service codes better reflect the reason for a sports physical to prevent injuries from occurring, [...]

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