Although these exams are preventive in nature and the patient does not generally present with any signs or symptoms, official CPT instructions from the American Medical Association (AMA) make clear that the "Preventive Medicine Services" codes (99381 to 99429) are to be used to report such preventive visits only when the patient history and physical examination are "comprehensive." The CPT code book itself is unclear how to report such preventive visits when, as is generally the case with these types of physicals for administrative purposes, a less-than-comprehensive history or examination is provided.

Fortunately, the AMA provides other sources for official CPT commentary besides the code book itself. The AMA actually has ten official sources for commentary on how to properly use the coding system. These official sources are:

• The annual CPT code book
• The monthly CPT Assistant newsletter
• The bimonthly CPT Assistant Plus Clinical Examples: Coding from Procedure Reports newsletter
• The quarterly CPT Assistant: Clinical Examples in Radiology newsletter
• The annually-revised CPT Companion book
• The annually-revised CPT Changes: An Insider's View book
• The various editions of the Principles of CPT Coding book
• Official responses to questions posed to the AMA's CPT Information Services
• Official responses to questions posed to the AMA's CPT Network online coding resource
• Official commentary found in the AMA's CPT Network online coding resource 

The matter of physicals for drivers licenses and camp and school physicals seems fairly comparable to "sports physicals." The AMA has officially addressed the issue of such "sports physicals" on three separate occasions: the first was in the July 1996 issue of The CPT Assistant, the second was in the August 1997 issue of The CPT Assistant, and the third was in the 1999 edition of The CPT Companion book. Although this topic appears in the 1999 edition of this book, interestingly, it does not appear in the 2000 and 2001 editions of this book.

Here is the exact verbiage from these three citations:

From the July 1996 issue of The CPT Assistant:

Question: What code should I use to report a "sports" physical?

AMA Comment: If the physician performs a comprehensive history and examination, then you should 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.

From the August 1997 issue of The CPT Assistant:

Question: What code should I use to report a "sports physical" or a "school physical?"

If the physician performs a comprehensive history and examination, then you should report the age appropriate code from the preventive medicine series. If the physician performs a problem focused, expanded problem focused or detailed history and examination, then report  the appropriate level office or other outpatient evaluation and management visit code.

From the 1999 edition of The CPT Companion book:

Question: What code should I use to report a "sports" physical?

AMA Comment:  If the physician performs a comprehensive history and examination, then you should report the age appropriate code from the preventive medicine series. If the physician performs a problem focused, expanded problem focused or detailed history and examination, then report  the appropriate level office or other outpatient evaluation and management visit code.

Coders often suggest an alternate coding method of appending the -52 modifier to an otherwise appropriate "Preventive Medicine Services" code. While this is, indeed, a common-sense solution to this coding problem (and indeed, this is exactly how some payers prefer to have such services reported), the AMA makes clear that such a coding strategy is inappropriate from a strict CPT coding standpoint. Fortunately (or unfortunately as the case may be), the AMA's CPT Information Services has provided the following response, dated April 13, 2001, regarding the alternate coding method of appending the -52 modifier to an otherwise appropriate Preventive Medicine Visit code:

From a coding perspective, 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.  Instead, the appropriate Office or Other Outpatient  E/M Service code should be reported based upon the key components that are met (i.e., history, physical exam, medical decision making).

Having a clear method, such as this official coding instruction provided by the AMA, to report such less-than-comprehensive Preventive Services is especially important since more and more payers offer coverage of such limited physicals as a covered policy benefit.

If billing such a less-than-comprehensive Preventive Services visit to Medicare to get a denial from them so that you may then bill the patient or secondary payer, it may be important to consider using the -GY modifier, lest your carrier think you provided a covered E/M visit. Using the -GY in conjunction with an appropriate screening ICD-9-CM code should be all the information the Medicare carrier would need to make the correct determination that the service is a preventive, screening service.

Greg Schnitzer, CodeRyte, Inc.

CPT is copyright 2006 American Medical Association.  All Rights Reserved.  No fee schedules, basic units, relative values, or related listings are included in CPT.  The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.