Get Paid for Physicals

Physicals don't need to be a painful exercise in billing at your medical practice if you get the coding and reimbursement details right. Here's how to do it.

There's one surefire way to make a room full of physicians groan in unison: start talking about billing -- and getting paid -- for physicals.

Billing for physicals is confusing, but getting it right means getting paid. Many physicians, especially those in primary-care specialties, will do a dozen or more of these exams a day during August as children, teenagers, and young adults head back to school. There are right and wrong ways to code these exams.

If you perform a comprehensive physical, choose a procedure code from the Preventive Medicine codes CPT 99381-99387 for a new patient, or CPT 99391-99397 for an established patient, and select the code based on the patient's age. For example, use CPT 99384 for an initial comprehensive preventive medicine exam of an adolescent, age 12 through 17 years.

Coding comprehensive physicals is fairly simple, but what about those not-so-comprehensive physicals that your patients often request?

There are many occasions to perform noncomprehensive physicals: adoptions, summer camps, sports participation, obtaining a driver's license, marriage, and school attendance -- so many, in fact, that the American Medical Association (AMA) addressed the issue in one of its CPT Assistant newsletters:

"If the physician performs a comprehensive history and examination ... report the age-appropriate code from the Preventive Medicine series. If the physician performs a brief, detailed, or extended history and examination, then report the appropriate level office or other outpatient evaluation and management visit code."

How not to code

While there appear to be several options in how to code a noncomprehensive physical, several widely practiced methods are wrong, and will likely result in a denied claim.

For example, instead of selecting the appropriate E&M code as the AMA suggests, some physicians code noncomprehensive physicals by appending the comprehensive preventive medicine code for the physical with the -52 modifier to indicate "reduced service."

However, the AMA advised physicians against this coding practice, saying that, "it would not be appropriate to append modifier -52, reduced services, to a preventive medicine evaluation and management (E&M) service code when only a brief history and examination is performed." The statement continues by saying that the appropriate office or other outpatient E&M service code should be reported based on the key components that are met, such as history, physical exam, and medical decision-making.

Another example of inappropriate coding involves sports physicals. Some physicians use CPT 97005 (athletic training evaluation) or CPT 97006 (athletic training re-evaluation) for these exams. These codes represent problem-oriented services so they are not appropriate for any type of physical. However, they might be appropriate if you examine a football player who presents for an evaluation of a knee injury received while playing the sport.
If the encounter does indeed start off as a physical, but becomes a problem-oriented visit, then document it as a problem visit and code it as such.

You can bill for both a problem-oriented visit and a physical by appending the -25 modifier to the problem-oriented visit, which indicates that the problem was a "separately identifiable" service. Because it is rare that an insurance company will pay you for two or more E&M codes used during one office visit, some physicians now choose to proceed with the problem-oriented visit and ask the patient to reschedule the physical for another day. This recommendation may not be suitable for all practices, but it is one to consider if you feel you're not receiving adequate reimbursement for your time. However you decide to handle these situations, follow a consistent policy so your billing staff knows how to respond if questions are raised about these claims.

Keep in mind that a problem-oriented E&M visit is much more likely to be reimbursed than a physical. It is not uncommon for patients to ask their physicians to "discover" a problem during a physical when they learn that their insurance doesn't cover a service they want.

Billing for a service you didn't render is a ticket to civil or, possibly, criminal court if it's discovered. Explain to patients that you cannot legally bill their insurance company for something you didn't do, and as a conscientious physician you are not going to perform services that aren't medically necessary.

Preoperative exams


One of the most hotly contested issues regarding physicals is the preoperative exam. Most physicians agree on its medical necessity, but many insurance companies do not.

Fortunately, the Centers for Medicare and Medicaid Services (CMS) stated that the examinations "are payable if they are medically necessary and meet the documentation requirements of the service billed. Determination of the appropriate E&M code is based on the requirements of the specific type and level of visit or consultation the physician submits on his claim (e.g., established patient, new patient, consultation)."

The American Academy of Family Physicians (AAFP) suggested fully documenting those requests in the patient's record, e.g., "Ms. Jones seen at the request of Dr. Smith, who is requesting preoperative clearance due to X."

The AAFP also suggested sending a written report to the requesting surgeon and using a consultation code to report the preoperative visit. The consultation codes can only be used if you actually meet these requirements of a consult: (1) request for opinion; (2) rendering of the service; and (3) response in writing. For a service in the office, use an office consultation code (99241-99245); at the hospital, use an initial inpatient consultation code (99251-99255). In either case, choose the level of service based on the level of history, exam, and medical decision-making; all three key components must be met.

If the exams are rejected due to coding issues, tell the carrier you are following Medicare's rules and ask for an explanation of the appropriate coding for the carriers' beneficiaries.

Coding for workers

If you treat patients for injuries they received on the job, learn your state's specific rules for workers' compensation. If you provide independent medical examinations (IMEs), the specific codes for a "work-related or medical disability examination" are either CPT 99455 (by the treating physician) or CPT 99456 (by other than the treating physician). Since the AMA's guidance for CPT coding notes that the work you are describing includes "completion of necessary documentation/certificates and report," you cannot bill for these services separately.

There's another way to bill physicals and it is completely outside of the realm of the CPT coding system. Some physicians contract directly with local employers to offer physicals to their workers, including pre-employment physicals, employee lab screening, and executive physicals. In these arrangements, the physician provides the services defined in a contract with the employer and invoices the employer directly. No insurance is involved and no CPT codes are necessary.

Make the diagnosis

Procedure codes are complicated, but don't forget about the diagnosis codes. Since there is no patient complaint when a physical is requested, look to the V codes for the appropriate diagnosis code. The most common diagnosis codes for physicals are:
¥ V70.0. "Routine general medical examination at a healthcare facility," which includes health check-ups for adults 18 years of age and above.
¥ V70.3. "Other medical examination for administrative purposes," which includes school and sports physicals, as well as exams needed to get a driver's license or a marriage certificate.
¥ V70.5. "Health examination of defined subpopulation," which includes employment physicals and workers' compensation physicals.
¥ V20.2. "Health check-up of a child," which includes all well-child check-ups for children aged 0 to 17 years.
¥ V72.3. "Gynecological examination," which includes a well-woman exam.
¥ V72.81-V72.85. "Other specified examinations," which include preoperative cardiovascular examinations and preoperative respiratory examinations. Choose from these diagnosis codes for preoperative physicals.

This is not an inclusive list; use your ICD-9 book to determine the code that best fits the service you provide.

Always link the diagnosis code to the proper CPT code, especially if you perform more than one service during the visit. For example, if a patient is seen for a problem but also requests her annual well-woman exam during the visit, bill the preventive visit and use the E&M code to describe the problem visit with a -25 modifier to indicate that it is a separately identifiable service.

Get paid

Many patients are covered by insurance products that specifically exclude physicals and many other preventive medicine services. The best-known example is Medicare, although its beneficiaries do have coverage for a limited number of preventive services such as colonoscopies.

No matter what the patient's insurance, take these steps to ensure payment when coding and billing for a physical exam:

  • Get details about the patient's coverage before the appointment. Even plans that include preventive medicine services might only cover them up to $500 or some other amount annually. Use the online benefits information portals that many carriers offer to providers or get on the telephone and talk to an insurance company benefits representative before the day of the patient's appointment.
  • Update the patient. Contact the patient immediately if you learn that a scheduled physical will not be covered by insurance. Tell her that she will be financially responsible and for how much. Those who know they have to pay for a service are more likely to pay; those who don't will be frustrated, angry, and more likely to resist payment.
  • Get waivers for noncovered services. If the patient still wants the noncovered physical, ask her to read and sign an insurance waiver confirming her financial responsibility for the service. Download a template from the Tools section of
    www.PhysiciansPractice.com. Since this situation often comes up with Medicare patients, use the Medicare form for non-covered services, known as the "Advance Beneficiary Notice," and review its terms of use (also on www.PhysiciansPractice.com).
  • Collect payment. If there's any doubt about whether insurance will cover the physical, collect at least the patient's copayment on the day of the encounter.
  • Submit the claim. Send the claim to the patient's insurance company with the appropriate CPT and diagnosis codes. If the service is not covered by insurance, bill the patient for the remaining balance unless, of course, you have a contractual obligation to provide these services at no cost to the patient.

Physicals don't need to be a painful exercise in billing if you get the coding and reimbursement details right. They are an important service to offer patients, and one of the best ways to market your practice because "well" patients almost always need some "sick" care. If you understand how to code them, you'll be way on your way to getting paid and perhaps picking up some new patients.

Elizabeth Woodcock, MBA, FACMPE, CPC, is a professional speaker and consultant specializing in practice management. She has focused on medical group operations and revenue cycle management for more than 13 years, has delivered presentations at regional and national conferences, and has authored several practice management manuals and textbooks. Ms. Woodcock completed an MBA in healthcare administration from The Wharton School of Business of the University of Pennsylvania. She can be reached at ewwoodcock@mindspring.com.

This article originally appeared in the July/August 2004 issue of Physicians Practice.