Alicia: Sports Physical
Q: If a provider has coded a V70.3 sports physical & throughout document states and
supports the well child check V20.2 and he has charged out an (regular E&M 99213 with
V70.3) is a coder allowed the change the codes to preventative code 99383 with V20.2 as long
as documentation is there?
A: Could you do this?
Yes, you could.
You got the documentation and everything.
But would you want to do this?
Probably not.
I can give you a reason why.
Some insurance [Ed.
Note: companies] are not going to pay for sports physicals.
And so again, you might have a reason to do a well-visit but if you make a change and
there is a well-visit scheduled there's going to be a major conflict because you can only
do a well-visit from insurance companies once a year.
At least I don't know of any that will let you do more than once a year unless the baby
is under one and they have to do a 6-month check-up and a 9-month check-up.
I went out and I found the example of the yearly well-visit exam versus sports physical
only that a clinic actually put out to the patients to let them kind of pick and choose
and why, and it just seems like I could explain it so much better than I could have.
What they're saying is: "A YEARLY WELLNESS EXAM includes a comprehensive exam along with
teen education, self-screening instructions, a urinalysis, complete blood count and completion
of the sport's physical form."
For a young woman who needs a pap as well, they can schedule that and it can all be done
at the same time for the yearly wellness.
But, they make a note here that said: "the yearly wellness exam at the same time as most
insurance plans only pay ONE yearly wellness exam in a year."
In other words, if you want to combine all of that for a girl, she had the pap; because
if she had to come back and have pap, they may not pay for it.
"If YEARLY WELLNESS EXAMS are covered by your insurance plan and your child has not had
a wellness exam in the last year, this would be a good option for you to choose."
So, if you have decided to just go ahead and change that and your patient had actually
had a wellness exam three months prior or has one scheduled in two months, you or more
less knocked out that visit or you're not going to get paid if they'd already had one.
"THERE WILL BE NO DISCOUNTED FEES FOR THIS EXAM and all charges will be submitted to
your insurance plan.
YOU WILL BE RESPONSIBLE TO PAY FOR YOUR CO-PAY, IF APPLICABLE, AT THE TIME OF THE SERVICE."
They are just explaining why you have to make the decision what you want them to do.
"If you are unsure what your insurance plan covers or what your co-pay is, please check
with your insurance company PRIOR to choosing an option" -- and that "prior" is a good point.
I actually made that bold and underlined it because again before you make that decision
to change the coding you need to make sure that the patient will benefit from this and
it won't be a negative for the payer.
"DO NOT have insurance coverage for this, the entire amount will be due at the time
of the exam.
We realize that not all insurance plans pay for yearly wellness exams so we offer a second
option of sports physical only."
Then, it goes in to just say what the sports physical is, what they'll actually do, and
they're just going to charge them a $35 fee , and flat fee for actually doing the sports
physical.
Again, be very careful, can you do it?
Well yes, you've got all the documentation and stuff and he's put that down.
But, be very careful; definitely check with the patient and make sure the patient understands
their insurance coverage and there's no overlap there.
Again, a lot of times the people don't understand the insurance coverage and don't even know
if a sports physical would be allowed or if they have well-visit coverage and such.
So, the question is, can you do it?
Yeah.
Would you do it?
No, I don't think I would.
Let them code for what they're being seen for.
So, if it's sports physical, code for that.
If it's a well-visit, code for that unless you have specific instructions between -- the
communication between you, the patient, and the physician.