Sports Physicals: A Coding Conundrum

Here's how to make sure you get paid for this common and valuable service.

Cindy Hughes, CPC

Nearly 7 million students take part in high school sports activities each year.1 Each of them most likely was required to provide proof that he or she was healthy enough to participate. This proof usually takes the form of a preparticipation or sports physical.

Because CPT does not have a code to report a sports physical, physicians are often uncertain about how to bill for it. There's no easy answer, but this article should help you untangle the issues. And although the article focuses on sports physicals, keep in mind that these same reimbursement strategies may work for camp physicals, pre-employment physicals, commercial driver's license physicals and other noncovered evaluative services without codes.

What works?

It may help to begin by explaining why two common approaches to coding for sports physicals don't work very well. One involves reporting a preventive medicine code with a -52 modifier to show reduced services. Because the sports physical lacks many of the elements of an age- and gender-appropriate comprehensive history, examination, counseling and anticipatory guidance - all requirements for codes 99383-99385 and 99393-99395 - you should not use a preventive medicine code.

Another approach that is problematic, although it may work for some payers, is to use the office and other outpatient services codes (99201-99215). The AMA's CPT staff has advised using these codes to report preventive services that are less than comprehensive, and Tricare/Champus requires that sports physicals for its beneficiaries be coded this way. However, many payers' claims processing systems automatically reject claims that list problem-oriented visit codes with preventive-oriented diagnosis codes, so check with your payers before adopting this approach. Even if your claims are paid when coded this way, you'll want to be sure your documentation includes the chief complaint and key components required for the level of service you're reporting. This could be challenging because the requirements for the office visit codes are problem-oriented. Using an office visit code to bill for a sports physical is like trying to fit a square peg into a round hole. You might succeed, but not without difficulty.

If you can't use office visit codes for sports physicals, how should you code and bill for them? You have a couple of options. Each requires proactive effort to determine what the patient's health plan covers and how best to report the services:

Perform a full preventive service and bill the health plan. Most payers reimburse one preventive exam annually or provide fixed-dollar support for preventive services provided during a calendar year. Where this is the case, using the benefit for a limited sports physical is not advantageous to you or the patient. If the patient has not had a full preventive service in the last 12 months, the scheduler should inform the parent when he or she calls for an appointment that a full preventive service is recommended and that the sports physical form can be filled out in conjunction with the preventive visit. It may be beneficial to develop a patient handout such as the one below to emphasize the importance of a well-child exam.

Perform a sports physical and bill the patient. For cases where the patient's preventive service benefit has been exhausted by a full preventive exam in the last year or the patient's health plan won't pay for a sports physical under any circumstances, you should set a fee and instruct your scheduler to inform anyone wishing to schedule a sports physical that it must be paid for at the time of service. Most computerized billing systems allow you to set up codes for services that are not billed to insurance. These are often alphabetical codes, so as to avoid confusion with CPT codes (e.g., "sport"). This enables the practice to track utilization data and to generate itemized statements. You should ensure that the statement provides a detailed description of the service for the benefit of parents with health care reimbursement accounts and those who track health care expenses for tax purposes.

In the end, it's the same old story. Your staff must make the effort to find out what the plans common in your practice cover and how they want services reported. If the sports physical is noncovered and can't be provided in the context of a full preventive service, you should have policies in place to bill patients directly.

Comments? fpmedit@aafp.org.

1. National Federation of State High School Associations Participation Survey 2005-2006. Available at: http://www.nfhs.org. Accessed Sept. 22, 2006.

About the Author

Cindy Hughes is the coding and compliance specialist for the AAFP and is a contributing editor to Family Practice Management. Author disclosure: nothing to disclose.