How do I bill a school physical visit for a 6-year-old child covered by Medicaid (Medical Assistance Program)?

Billing for a School Physical for a 6-Year-Old Medicaid Patient

For a 6-year-old child with Medicaid coverage coming in for a school physical, you should bill 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

Appropriate CPT Coding

• Use preventive medicine service codes based on the patient's status:

  • 99383 for new patients ages 5-11 years 1
  • 99393 for established patients ages 5-11 years 1

• 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 1

• Document that this is a school physical in your notes to support medical necessity 2

Medicaid-Specific Considerations

• 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 1

• Medicaid requires no copayments or cost-sharing for EPSDT services, making these visits fully covered for the patient 1

• If additional services beyond the preventive visit are provided (such as treatment of an acute condition), you may bill for both services with appropriate modifiers, though some state Medicaid programs may have restrictions on same-day billing 1

Documentation Requirements

• Ensure documentation includes all required elements to support the preventive medicine code:

  • Comprehensive age-appropriate history
  • Comprehensive examination
  • Counseling/anticipatory guidance
  • Risk factor reduction interventions
  • Immunization status review and administration as needed
  • Any screening tests performed 1, 2

• Document the medical necessity for the school physical (required for school enrollment/participation) 2

Additional Services and Billing

• If immunizations are administered during the visit, bill the appropriate vaccine administration codes (90460-90461) and vaccine product codes in addition to the preventive visit code 1

• For any laboratory tests ordered, bill separately using the appropriate CPT codes 2

• 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

Common Pitfalls to Avoid

• Don't substitute a brief sports physical for a comprehensive preventive examination, as Medicaid covers and expects the full preventive service 1

• Avoid upcoding by selecting a higher E/M level than supported by your documentation 2

• Don't charge the family any out-of-pocket costs for EPSDT services, as this is prohibited under Medicaid rules 1

• Be aware that Medicaid payment rates are often lower than Medicare or private insurance rates, but providers cannot balance bill Medicaid patients 1