The “sports physical,” also referred to as a “preparticipation physical evaluation” is a type of physical exam that focuses on identifying conditions that may prevent an athlete from safely participating in sports or that pose a higher risk of injury, illness or even mortality. Sports medicine physicians who provide this service have significant specialized training in both the treatment and prevention of illness and injury. This sports physical, which is often requested before students go to college or camp, also helps detect physical and or psychological ailments. As payer policies differ, coding for sports physicals can be a challenge. Medical billing companies specialize in sports medicine medical billing are knowledgeable about payer guidelines and can help physicians report these evaluations correctly on claims.
What does the sports physical involve?
The sports physical is separate from the comprehensive well-child exam. These evaluations can be done independently or together and physicians should get reimbursed for the work they perform. The components of a comprehensive preparticipation physical exam are:
- Medical and Family History: The physician enquires about serious illnesses among family members, previous hospitalizations, past injuries, allergies, current medications, and so on. Medical history is generally considered the most important component of the evaluation as illnesses in the family can provide an indication of conditions the patient may have. The physician will also enquire if the patient takes anabolic steroids, or has used any other supplement to boost performance.
- Physical Evaluation
- General Health Evaluation: This will involve recording the patient’s vital signs, height, weight, blood pressure and vision testing, pulmonary testing, and other tests.
- Cardiovascular Screening: The aim is to assess for heart murmurs, femoral pulses, and blood pressure measurements.
- Neurologic Evaluation: This will include sensory testing, motor control testing, and reflex examination.
- Orthopedic Assessment: This will include examining all joints for injuries and evaluation of strength, posture, flexibility, deformities, instabilities, and asymmetries.
- Nutritional Assessment: This involves evaluation for eating disorders as well as mental health issues and psychological factors.
- Heat and Hydration-related Risk Factors: Athletes’ risks for heat-related illnesses are assessed.
- Mental Health Assessment: By assessing for psychiatric disorders, athletes can be treated before they return to the sport.
Coding the Sports Physical
To ensure claims for sports physicals are paid, an AAPC article recommends that providers establish a policy for billing these evaluations for every payer they accept. Let’s take a look at how payers’ policies on billing sports physicals differ.
- Texas Children’s Health Plan: Texas Children’s Health Plan provides reimbursement for sports physicals as a value added service for CHIP and STAR Members under 21:
- Reimburses only code 97169 – Athletic Training Evaluation, low complexity (other Athletic Training Evaluation codes such as 97170-97172 are not reimbursed)
- Code 97169 is only reimbursed for sports and camp physicals when a member has also had a
- THSteps or well child visit within the previous 12 months
- Members aged 5 – 19 (STAR & CHIP), 5 – 20 (STAR Kids) who have had a Texas Health Steps check up in the last 12 months will be eligible for one annual sports and school physical by their Primary Care Physician (PCP)
- Providers may be reimbursed for sports physicals performed at the same time as a Texas Health Steps checkup or during a separate medical visit.
When a child is scheduled for a sports physical, it is recommended that providers determine if child is due for a Texas Health Steps check-up also, and complete all components for both these services.
- Superior HealthPlan: Superior covers sports physical as a value added service for eligible members:
- STAR, STAR Health and CHIP members only
- Ages 4-17 (STAR and CHIP) and ages 4-18 (STAR Health)
- One (1) per calendar year
- Relevant codes to use in claims are:
- Diagnosis Code: Z02.5
- CPT Codes: 99382-99385 or 99392-99395
A sports physical is distinct from a Texas Health Steps checkup. Superior recommends that the provider completes the Texas Health Steps checkup for a child who is due for this checkup, and provide complete documentation for the sports physical.
- Wellcare of Nebraska: All children who turn 5 on or before July 31 are eligible to start public kindergarten in the state of Nebraska. Even if they don’t start at 5, Nebraska state law requires that all children begin school the year they turn 6 before December 31. The state of Nebraska requires a school physical for entry into kindergarten and again for seventh grade within six months of beginning school.
- Nebraska Medicaid allows one Early and Periodic Screening, Diagnostic and Treatment (EPSDT) visit per year for ages 4 to 21 years
- If the member’s annual EPSDT exam does not occur within the six months before the beginning of school, an additional EPSDT exam may be needed based on specific criteria
- Wellcare of Nebraska Sports Physical Exam for School: The appropriate level Evaluation and Management code is the appropriate code for the school sports exam:
- 99201-99205 for a New Patient exam
- CPT 99212-99215 for an Established Patient exam.
- The –EP modifier is not applicable and should not be billed
- Only the diagnosis code for school physical exam shall be used: Diagnosis code Z02.5-Encounter for examination for participation of sport
- Amerigroup (an Anthem Company): Amerigroup provides coverage for sports physicals as a value-added service:
- For STAR and CHIP members (ages 4-19), STAR Kids (ages 0-20) when performed by an in-network primary care provider
- Coverage for sports physicals is limited to one every 12 months
- If the member is due for a Texas Health Steps checkup or CHIP well-child checkup, the provider should complete both the sports physical and all the components required for the annual checkup
- Providers may bill and receive reimbursement for both services, though a sports physical is not a reason for an exception-to-periodicity checkup.
- CPT code 99212 and diagnosis code Z02.5 should be used to bill for a sports physical. No additional modifier is needed.
Sports physicals are distinct from well-child visits. To get paid for this additional work provided along with the well-child exam, providers need to document their services correctly. Lack of consensus among payers’ policies can make coding sports physicals complex. Orthopedists and other sports medicine specialists who provide sports physicals can rely on outsourced medical billing and coding services to report their services correctly to meet payer guidelines. Orthopedic medical billing by an expert can ensure proper billing and reimbursement for preparticipation evaluations.
With the increase in the number and type of sports injuries, orthopedic medical billing and coding is becoming rather complex. Outsourcing medical coding tasks is a practical option to ensure accurate clinical documentation that is vital to provide appropriate care.
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The COVID-19 pandemic has altered people’s lives in many ways. This year, we covered almost all COVID-19 related medical billing and coding topics and have seen huge page views for related blogs. As we are heading to 2021, we are sharing our top 10 most popular and insightful blog posts of 2020.
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- Telemedicine Coding and Billing During the COVID-19 Pandemic
As COVID-19 cases were skyrocketing in the U.S., telemedicine also emerged as an important tool to better care for people who contracted the virus. Digital office visits allowed symptomatic patients to stay at home and communicate with physicians on the status of their health, while protecting healthcare workers and the community at large. Many practices continue to rely on telemedicine. In this blog, we have shared important details on telemedicine coding and billing during the covid-19 pandemic.
- COVID-19 – New CPT Code for Lab Testing and Revised Specimen Handling Guidelines
As a medical billing company, we keep up to date with billing and coding changes and report on current and emerging healthcare issues. In March 2020, we shared details of a new coronavirus (COVID-19) CPT code and description for testing which came into effect on March 13, 2020. Also, we have updated a CDC-issued revised specimen handling guideline. To know more about this new code and revised guidelines.
- New ICD-10 Codes for Atrial Fibrillation in 2020
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- CPT Code Updates Impacting Orthopedics in 2020
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- Major CPT Code Changes for Long-term Electroencephalography (EEG) in 2020
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- COVID-19: CDC Issues Recommendation to Preserve and Optimize the Supply of PPE
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- ICD-10 and CPT Coding Updates for Urology in 2020
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People get engaged in sports activities to maintain an active and healthy life. However, it can be a common source of injury. Generally, injuries are of different types which occur as a result of repetitive movements caused by over-stretching of the muscles and ligaments, poor training practices, collisions, sudden movements, improper use of equipment and changes in direction. Achilles tendinitis is one such overuse injury of the achilles tendon – the band of tissues that directly connects the calf muscles at the back of the lower leg to your heel bone or calcaneus. It most commonly occurs in runners who have suddenly increased the intensity or duration of their runs. It also occurs in middle-aged people who engage in sports activities like tennis or basket ball. If left untreated, the injury can make the tendons to tear or rupture. In mild cases, treatment may involve resting or changing an exercise routine, but more severe cases may require surgical repair. Orthopedic medical billing and coding to document such injuries can be time-consuming and challenging. Outsourcing all or part of the medical billing and coding tasks would allow practitioners to focus on their work without worrying about the documentation process.
Types and Causes of Achilles Tendinitis
Generally, Achilles tendinitis can develop in different ways. Some cases of tendinitis are easier to avoid, and diagnosing the condition at an early stage can help prevent serious injury. Achilles tendinitis is of two different types – insertional and non-insertional Achilles tendinitis.
- Insertional Achilles tendinitis – This type of tendinitis affects the lower portion of the tendon where it attaches to the heel bone. The condition is not necessarily related to activity.
- Non-insertional Achilles tendinitis – More common in young, active people, the condition involves fibers in the middle portion of the tendon starting to break down, thicken, and swell.
Any repeated or intense activity that strains the achilles tendon can potentially cause tendonitis. As people age, the structure of the tendon weakens which makes it more susceptible to injury (particularly in people who have increased the intensity of their sports activities). Other related causes include –
- Exercising without proper warm-up
- Straining the calf muscles (during repeated exercise or physical activity)
- Wearing old or poorly fitting shoes
- Wearing high heels daily or for prolonged durations
- Sudden increase in physical activity (without allowing your body to adjust to increased training)
- Running on hard or uneven surfaces
- Playing sports (such as tennis) that require quick stops and changes of direction
- Having bone spurs in the back of your heels
Achilles Tendinitis Symptoms
Pain and swelling that begin as a mild ache at the backside of the leg or above the heel (after running or other sports activity) is one of the main symptoms associated with the condition. In addition, people may also experience tenderness or stiffness, especially in the morning, which usually improves with mild activity. Other related symptoms include –
- Discomfort or swelling in the back of the heel
- Tight calf muscles
- Limited range of motion when flexing the foot
- Skin on the heel overly warm to the touch
A number of factors can increase the risk of this condition which include – age, medical conditions (like psoriasis or high blood pressure), physical problems (like obesity and tight calf muscles), incorrect training choices, and use of certain medications (certain types of antibiotics called fluoroquinolones).
Diagnosing and Treating Achilles Tendinitis
Diagnosis of this condition generally begins with a detailed medical history evaluation by the physician. Patients will be asked about the pain and swelling in the heels or calf. A detailed physical examination will also be performed wherein the physician will gently press on the affected area to determine the location of pain, tenderness or swelling. Orthopedists may also ask patients to stand on the balls of their feet while observing their range of motion, alignment and flexibility of the foot and ankle. They may also perform imaging tests like X-rays, Magnetic resonance imaging (MRI) scans (that detect ruptures and tissue degeneration) and Ultrasounds (to analyze tendon movement) that help rule out other possible causes of pain and swelling and to assess any damage to the tendon.
Treatment modalities for this condition can range from self-care strategies like rest and anti-inflammatory medication, to more invasive treatments like steroid injections, platelet-rich plasma (PRP) injections, and surgery. In most cases, the RICE method (comprising rest, ice, compression, and elevation) is usually effective in treating Achilles tendonitis right after the tendon gets injured. Orthopedists may also suggest medications (like over-the-counter pain medications such as ibuprofen (Advil, Motrin IB, others) or naproxen), physical therapy exercises (like stretching and strengthening), and orthotic devices to relieve strain on the tendon. If any of these conservative treatment modalities don’t yield in the desired results or if the tendon has torn, surgery may be recommended to repair the achilles tendon.
Orthopedic medical coding involves using the specific ICD-10 diagnosis codes to report various orthopedic conditions such as Achilles tendon on the medical claims. Medical billing and coding services are available for orthopedists to help with timely documentation and claim submission.
ICD-10 diagnosis codes for achilles tendon include –
- M76.6 Achilles tendinitis
- M76.60 Achilles tendinitis, unspecified leg
- M76.61 Achilles tendinitis, right leg
- M76.62 Achilles tendinitis, left leg
The common complications associated with Achilles tendonitis is pain, having trouble walking or exercising, and the tendon or heel bone becoming deformed. Tendinitis usually goes away after a few days, following rest and proper home treatment (including the RICE method). However, recovery may take a longer time if the patient continues to put pressure on the tendon or doesn’t change exercise habits to prevent another injury or rupture. Seeking proper treatment for the ruptured tendon is very important. In addition, carefully following the physician’s instructions will give patients a much better chance for a quick recovery. Incorporating certain self-care strategies like stretching the calf muscles, combining high- and low-impact exercises, choosing shoes with proper cushioning and arch support, and reducing the heel size of the shoes can help prevent the occurrence of Achilles tendinitis in the long run.
As orthopedic medical billing and coding is challenging and time-consuming, physicians can consider hiring medical coding services. This would ensure accurate reporting of diagnostic details and help avoid delayed / denied claims.
Joint and other musculoskeletal injuries can occur at any age, particularly for those who engage in repetitive activities. Knee overuse injury is one such common injury. Injuries to the knees generally occur due to performing repetitive motions. Many overuse injuries result from doing too many exercises or activities too soon. On a general mode, exercise and activity can strengthen muscles, bones, tendons and ligaments through a process known as remodeling (the break down and growth of new tissue). However, when the tissues break down faster than it can rebuild, injuries are bound to happen. Overuse knee injuries are generally caused from changing equipment like shoes (for a walker or runner) and using improper training techniques (that can strain certain muscles and joints). Certain medical conditions like flat feet, excessively arched feet, bowlegs, unequal leg length, and poor alignment of the spine, hips, and legs can also increase the likelihood of overuse injuries. Early diagnosis and appropriate treatment are essential to get better outcomes, or else knee injuries can result in pain, swelling and loss of function. Orthopedic medical billing and coding can be challenging for physicians treating knee injuries. Proper documentation is important to ensure appropriate care and for accurate clinical documentation physicians can rely on the service of a reliable medical billing company.
Generally, overuse knee injuries are common in children and adolescents, especially when they repeat the same activity over and over again. Symptoms of the condition can vary based on the type and severity of injury and include – chronic pain, difficulty moving the knee, swelling, loss of sensation, tingling and numbness.
Here discussed are four common overuse knee injuries and their related ICD-10 codes –
Iliotibial Band Syndrome – One of the top causes of lateral knee pain in runners and bicyclists, iliotibial band syndrome (ITBS) is an overuse injury of the connective tissues located on the lateral or outer part of the thighs and knees. The condition causes pain and tenderness in that area, particularly above the knee joint. Typically, an overuse injury from repetitive movements, ITBS is caused by excessive friction from the IT band being overly tight and rubbing against each bone. Chronic pain on the lateral side of the knee is one of the most common symptoms of this condition. IT band syndrome diagnosis primarily begins with a medical history evaluation and physical examination. Physicians may perform certain types of body assessment by having the patient perform certain exercises to demonstrate movement patterns, strength, and stability. They may assess the alignment of the pelvis and tightness of the IT band. In some cases, diagnostic imaging tests like ultrasound, X-ray, or an MRI scan may also be performed. Treatment primarily focuses on conservative approaches like – non-steroidal anti-inflammatory drugs (NSAIDs), icing and stretching and strengthening exercises. Related ICD-10 codes include –
- M76.3 Iliotibial band syndrome
- M76.30 Iliotibial band syndrome, unspecified leg
- M76.31 Iliotibial band syndrome, right leg
- M76.32 Iliotibial band syndrome, left leg
Patellofemoral Pain Syndrome (PFPS) – Patellofemoral pain syndrome (PFPS) indicates pain in the front of the knee, around the kneecap (patella). Also called runner’s knee, the condition is more common in people who participate in sports activities that involve jumping and running. However, PFPS can also occur in non-athletes. Symptoms usually involve a dull, aching pain in the front of the knee. The severe pain and stiffness caused by this condition can make it extremely difficult to kneel down, sit for long periods, climb stairs, squat and perform other day-to-day activities. The exact factors that cause the pain condition are not known. However, a combination of factors like – muscle imbalances or weaknesses, overuse (from vigorous athletics or training), problems with the alignment of the kneecap, and knee surgeries may contribute to the development of the condition. Treatment for this condition usually begins with simple measures like resting the knee as much as possible and icing the knee area. Medications, physical therapy exercises, and supportive braces may also be recommended. In severe cases, if non-surgical treatments are not effective, physicians may advise surgical and other procedures like – arthroscopy and realignment (realigning the angle of the knee cap or relieve pressure from the cartilage). ICD-10 codes for a PFPS diagnosis include –
- M22.2 Patellofemoral disorders
- M22.2X Patellofemoral disorders
- M22.2X1 Patellofemoral disorders, right knee
- M22.2X2 Patellofemoral disorders, left knee
- M22.2X9 Patellofemoral disorders, unspecified knee
Patellar Tendinitis – Patellar tendinitis is an injury or inflammation to the tendon that connects the kneecap (patella) to your shinbone (tibia). The patellar tendon works with the muscles at the front of your thigh to extend your knee and make it possible for people to kick, run and jump. Also known as jumper’s knee, the condition is more common among athletes whose sports activities involve frequent jumping such as basketball and volley ball. People who do not involve in these sports activities can also experience this condition. Reports suggest that an estimated 40 to 50 of elite volleyball players have jumper’s knee. The condition occurs from repetitive stress on the knees, most often from overuse in sports or exercise. The repetitive stress on the knees may create tiny tears in the tendon which may in course inflame and weaken the tendons. Pain and tenderness at the base of the kneecap are one of the initial symptoms associated with the condition. In some cases, people may also experience swelling and a burning feeling in the kneecap. The pain may initially be irregular, occurring only after sports or exercise activity. As the tendon becomes more damaged, the pain can become progressively worse. Physicians may physically examine the knee, probe for the specific area of pain, and test the range of knee motion by bending and extending the leg. Imaging tests like X-Ray, MRI and Ultrasound may be performed to determine the severity of damage to the tendon or bone. Treatment for this condition depends on the extent and severity of the injury. Conservative measures like over-the-counter (OTC) drugs, physical therapy and injections will be the first line of treatment. Physicians will usually advise a period of controlled rest, where patients need to avoid activities that puts force on the knee. Surgery to repair the patellar tendon may also be considered if the conservative measures do not give in the desired results. Related ICD-10 codes include –
- M76.5 Patellar tendinitis
- M76.50 Patellar tendinitis, unspecified knee
- M76.51 Patellar tendinitis, right knee
- M76.52 Patellar tendinitis, left knee
Tibial Plateau Stress Fracture – Regarded as a complex injury of the knees, tibial plateau fracture occurs due to a break or crack at the top of the shin bone, at the knee. In most cases, it occurs as a result of trauma to the leg such as a fall from a height, a motor vehicle accident or other injuries from sports such as football or skiing. Other related factors that may increase the potential risk of the condition include – osteoporosis, infection or mineral deficiency that weakens the bones and makes them more susceptible to injury. Pain and discomfort in or around the upper part of the shin bone is one of the initial symptoms of the tibial plateau fracture. Symptoms include – bruising and swelling, pain in the joint with or without weight bearing, difficulty bearing weight on the leg, paleness in the leg ( due to decreased blood flow) and bone breaking through skin. Initial diagnosis of this condition is done by performing imaging tests such as an X-ray or an MRI or CT scan. Early detection and appropriate treatment of these fractures are essential in reducing patient’s disability in range of movement, stability and reducing the risk of other related complications. Treatment modalities include – resting the knees, splinting knee and not putting any weight on the injury, pain medications, applying ice pack, keeping your legs elevated and surgery (in severe cases). ICD-10 codes for this knee injury include –
- M84.36 Stress fracture, tibia and fibula
- M84.361 Stress fracture, right tibia
- M84.361A Stress fracture, right tibia, initial encounter for fracture
- M84.361D Stress fracture, right tibia, subsequent encounter for fracture with routine healing
- M84.361G Stress fracture, right tibia, subsequent encounter for fracture with delayed healing
- M84.361K Stress fracture, right tibia, subsequent encounter for fracture with nonunion
- M84.361P Stress fracture, right tibia, subsequent encounter for fracture with malunion
- M84.361S Stress fracture, right tibia, sequela
- M84.362 Stress fracture, left tibia
- M84.362A Stress fracture, left tibia, initial encounter for fracture
- M84.362D Stress fracture, left tibia, subsequent encounter for fracture with routine healing
- M84.362G Stress fracture, left tibia, subsequent encounter for fracture with delayed healing
- M84.362K Stress fracture, left tibia, subsequent encounter for fracture with nonunion
For mild or moderate injuries, basic self-care techniques like rest, icing and compression can help. Rest is essential, as you cannot stress the injured knee as it heals. Over-the-counter medications can help with reducing pain and inflammation. Compressing your knee with braces, sleeves, straps, or elastic bandages can provide adequate support while also reducing swelling, thereby promoting faster healing.
Billing and coding for different types of overuse knee injuries can be complex, as there are different codes associated with each specific condition. By outsourcing these tasks to a reliable medical billing service provider that offers the service of AAPC-certified coding specialists, healthcare practices can ensure accurate and timely medical billing and claims submission.