Billing for Sports Physicals

from Practice Update, Summer 2007

By Elizabeth Woodcock, MBA FACMPE, CPC

Summer is here, and your practice is flooded with requests for youth sports physical exams. If you look in the CPT® book for a code to use when billing these physicals, you’ll be disappointed. Sports and camp physicals—as well as those for pre-employment, flight and commercial driver’s licenses—are not addressed in the CPT code manual. So it’s no surprise that confusion abounds about how to code and bill for them.

Here are the straight answers about billing correctly for sports and camp physicals, and some tips to get paid.

Code as a physical when appropriate

There are a series of CPT codes for physicals based on the age of the patient. The American Medical Association (AMA) lists the services that must be performed to code for a physical. When your patient presents for a sports physical, but also needs a complete physical, ask the patient (or parent) if you can perform a full physical and include the sports physical as part of it. Better yet, when a patient (or parent) calls to schedule an appointment for the sports physical, look up or ask for the date of their last physical exam. If the child legitimately needs a full physical, request that they schedule an appointment for one. Tell them to also bring the forms their sports team, camp, etc., requires. They’ll be able to get those forms completed by you, as well as receive a complete check-up.

Don’t attach modifier -52

Most of the time, a sports or camp physical does not qualify as a physical as defined by the AMA. These exams are, in essence, a “shortened version” of a physical. That doesn’t mean you should use modifier -52 to bill for one. You will be missing too many elements (e.g., comprehensive history, examination, counseling, etc.) to qualify for this “reduced services” indicator. The only exception is if an insurance company directs you to attach this modifier, but get their directions in writing.

Don’t bill an office visit

Some physicians have decided that sports physicals can be billed as an office visit (99201-99215). Be careful about following this path because these office visit codes are, by nature, problem-oriented codes. It will be hard to justify using a problem-oriented code if your patient doesn’t have a problem. Now, suppose the visit does meet the criteria for a procedure code; the challenge becomes recording the diagnosis. By definition, a sports physical has no diagnosis. A physical will be billed with a preventive-oriented diagnosis code (i.e., an ICD-9 code in the V series). File an office visit with a preventive diagnosis code and that claim will likely get kicked back by the payer as an error. In sum, the only time you should bill an office visit when conducting a physical is if the patient has a service performed aside from the sports physical.

Set up a custom code 

If the patient (or parent) doesn’t want a complete physical and the child doesn’t have any medical problems, then bill them directly for the sports physical. Because sports and camp physicals are non-covered services, ask for, and expect, payment upfront. Set up a custom procedure code in your practice management system to generate a bill for the patient, not the payer.

You can set up other non-covered services, even no-shows, in the same manner. Terms like SPORT, CAMPP, or PHYSL would all be good choices for this custom code. Whatever path you chose, teach your staff to use that code. Integrate it onto your charge ticket or automatic charge entry form, attach a fee to that custom code ($25 to $50 is common), and request payment from the patient (or parent) at the time of service.

Most insurance companies won’t pay for sports physicals and other types of shortened physicals. Be upfront to parents and patients about your charges when they schedule the appointment. Undoubtedly, there will be some patients who need the service but cannot afford it. When patients truly need alternative ways to get low- or no-cost sports physicals, refer them to their child’s school, a community resource center or to the organization requesting the physical. Those parties have a desire to include participants, and may be able to offer them other routes to complimentary physicals.