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sports and camp physicals

Wanda Posted Mon 08th of August, 2016 14:24:15 PM
Will insurance companies cover sports and camp physicals within 1 year of an annual physical (before a patient is due for another annual physical)? We have run into the problem that schools are requiring an updated physical for sports prior to the time the patient is due for his/her physical, which requires the patient to pay out of pocket. How should it be billed it it's a possibility?
SuperCoder Answered Tue 09th of August, 2016 02:59:12 AM
Insurance companies cover sports and camp physical services on annual basis only. They do not cover for services performed before the next cycle. However, there are many private providers and centres that provide services any times of the year for a fixed amount of money. Insurances does not reimburse for such type of billing. However, some private payers may reimburse for the services. You need to get in touch with your insurance company for the coverage guidelines and policies of the company.
Wanda Posted Wed 10th of August, 2016 14:19:22 PM
Is there another code we can use such as a consult code instead of the preventative code in order to get the physicals for school/sports paid if the patient isn't due for their yearly physical?
SuperCoder Answered Thu 11th of August, 2016 02:48:06 AM

The other alternative would be to use Office Evaluation & Management visit codes (CPT codes 99201 – 99215), if only sports PE is performed, not the yearly exam, use the E/M office visit codes (99201-99215). However, many payers reject claims with these codes because they are considered to be used for “problem oriented” visits, which is not the case for a “well” visit with a diagnosis of general medical examination. Also, If limited service is provided to evaluate the patient in order to fill out the form, then CPT visit codes (99201-99215) can be used.

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