Sports Physicals: How to Code Them and Get Paid

If you are a family practitioner or pediatrician, you probably have had requests to complete sport physicals forms. This article addresses how to handle the coding and payment for such visits.

Since the sport physical visit is “preventive” in nature, one might assume that codes for Preventive Medicine Service (CPT codes 99381 – 99429) apply. However, these codes are intended to be billed when a comprehensive patient history and physical examination is performed, which is often not the case with sports physicals. The other alternative would be to use Office Evaluation & Management visit codes (CPT 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 ( ICD-9 code V70.3).

So, how should a practice bill for such visits? The following are three options.

    If the payer reimburses for one preventive physical per year, the provider can perform an annual comprehensive visit, and complete the sport physical form during this visit. This would be coded by using the age appropriate Preventive Service code (CPT codes 99381 – 99429).

    If the provider does not perform a comprehensive history and exam, a -52 modifier, indicating “reduced services” can be appended to the Preventive Service code. In this situation, please note that the insurance company may not pay for such a visit.

    The provider can create an office policy in which all sport physicals are considered “self-pay”, meaning that patients must be financially responsible and that a claim will not be submitted to their insurance company for payment. If this option is chosen, it is advised that cash is collected at time of service.

Before arriving at a decision, the key is to review your practice’s payer profile and inquire what services they cover and pay for. The last thing you want to do is bill for a preventive service and find out that that the insurance company does not cover it, forcing you to bill the patient. This can result in poor patient satisfaction and a negative reputation for the practice.

Lastly, to save time completing sport physical forms, it is recommended that practices using an Electronic Medical Record (EMR) develop an electronic template to avoid duplication of efforts. If the practice does not use an EMR, there are many software programs that allow users to create a standard template, complete it online, archive a copy and print a copy for the patient. By doing this electronically, the practice will save time.