Billing Guidelines for School Physicals in Medicaid Patients

Appropriate CPT Coding

For a 6-year-old child with Medicaid coverage coming in for a school physical, the American Academy of Pediatrics recommends billing using the appropriate preventive medicine service code (99383 for new patients or 99393 for established patients) with no copayment or coinsurance charges to the family 1, 2
The American Academy of Pediatrics suggests using preventive medicine service codes based on the patient's status: 99383 for new patients ages 5-11 years and 99393 for established patients ages 5-11 years 1, 2
These codes cover comprehensive age and gender appropriate history, examination, counseling/anticipatory guidance, risk factor reduction interventions, and ordering of appropriate immunizations and laboratory/diagnostic procedures, as recommended by the American Academy of Pediatrics 2, 3

The Centers for Medicare and Medicaid Services (CMS) states that school physicals are covered under Medicaid's Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, which provides comprehensive preventive health services for children under 21 2, 3
Medicaid requires no copayments or cost-sharing for EPSDT services, making these visits fully covered for the patient, according to the CMS 2, 5
The American Academy of Pediatrics notes that if additional services beyond the preventive visit are provided, you may bill for both services with appropriate modifiers, though some state Medicaid programs may have restrictions on same-day billing 1, 6

The American Academy of Pediatrics recommends ensuring documentation includes all required elements to support the preventive medicine code, including comprehensive age-appropriate history 1
The American Academy of Pediatrics suggests documenting comprehensive examination, counseling/anticipatory guidance, risk factor reduction interventions, immunization status review and administration as needed, and any screening tests performed 2, 5

The American Academy of Pediatrics recommends billing the appropriate vaccine administration codes (90460-90461) and vaccine product codes in addition to the preventive visit code if immunizations are administered during the visit 1, 2
The American Academy of Pediatrics notes that for any laboratory tests ordered, bill separately using the appropriate CPT codes 1, 6
The American Academy of Pediatrics suggests that if addressing a significant, separately identifiable problem beyond the scope of the preventive visit, you may bill an additional E/M service with modifier -25 (though check your state's Medicaid policy on this practice) 1, 6

The American Academy of Pediatrics advises against substituting a brief sports physical for a comprehensive preventive examination, as Medicaid covers and expects the full preventive service 1, 5
The American Academy of Pediatrics recommends avoiding upcoding by selecting a higher E/M level than supported by your documentation 1, 5
The CMS states that providers cannot charge the family any out-of-pocket costs for EPSDT services, as this is prohibited under Medicaid rules 2, 5
The American Academy of Pediatrics notes that Medicaid payment rates are often lower than Medicare or private insurance rates, but providers cannot balance bill Medicaid patients 1, 6