A sports exam, when not included in a preventive medicine encounter, is an office E/M visit. You can code it with these items:
A) for the CPT code, report an established or new E/M visit (99201-99215, Office or other outpatient visit)
B) link 99201-99215 to the ICD-9 code for an administrative examination (V70.3, Other general medical examination for administrative purposes).
If the physician uncovers a problem during the visit, 99201-99215 linked to the problem will especially support the visit. Insurers, however, may not consider V70.3 a covered diagnosis.
To avoid V70.3 non-coverage issues, try to schedule patients for preventive medicine services, rather thanfor sports physicals. Parents sometimes misinterpret the sports physical as the child or adolescent's complete annual physical examination. Having the patient come in for the annual ensures she receives the full service.
You would code a preventive medicine service as follows:
A) Use the age and status appropriate preventive medicine service code, such as 99394 (... adolescent [age 12 through 17 years]) for an established patient who is 15 years-old.
B) Link the adolescent preventive medicine service (99384 or 99394) to V20.2 (Routine infant or child health check) for children less than 18 years of age or the young adult preventive medicine service (99385, ... 18-39 years or 99395) to V70.0 (General medical examination; routine general medical examination at a health care facility) for adults. Check the payer's V20.2 cutoff age.
We can mention a couple of more strategies but first try with billing V20.2 or explaining Humana the total code descriptor of V70.3.
Strategy 3: Consider Forms Policy
For patients who have received a recent preventive medicine service, consider using that information to complete a sports form. Some pediatric practices have a set fee the patient pays for this service, such as a $20 forms fee.
Some practices will include completion of forms at the time of an E/M visit, but charge if the forms are brought in at another time. There is additional office overhead involved if the chart must be pulled and reviewed, the form completed, mailed, or faxed, and the chart refiled.
Pitfall: For liability reasons, your physician may not want to issue a form without checking the patient to see if his status has changed.
Strategy 4: Charge Parent
When a parent insists or the school requires an abbreviated exam on a patient who has not had a well check in the previous half of the year, you might want to implement a financial plan. Physicals required for sports are usually the patient's responsibility. Insurers typically do not cover the service.
If you expect the insurer will not cover the sports physical, have the parent sign an advance beneficiary notice (ABN). Make sure the parent understands she will have to pay if the insurer does not cover the sports exam, and notify her of the price.