A physical examination is that procedure which includes inspection, palpation, auscultation, and percussion of the systems of the body. A physical examination will be considered routine (and therefore, not covered) if it is performed at the request of the patient, employer, or at the suggestion of the doctor, without symptomatology or evidence of disease.

The following are some examples of routine (i.e., not covered) examinations:

1. Pre-employment
2. Required by law (e.g., physical examination needed for driver's license)
3. Required for admission to a nursing home
4. Required by insurance companies (initial coverage, status of disability)
5. Required by schools (either preadmission or periodic)
6. Performed as a prerequisite for engaging in physical activities

All diagnostic studies performed in conjunction with any of the above are not covered.

For purposes of payment, limited developmental testing (e.g., Developmental Screening Test II, Early Language Milestone Screen)(code 96110) is considered an integral part of a preventive medicine evaluation and management service (99381-99384, 99391-99394) and not eligible as a distinct and separate service. If the developmental testing is reported on the same day as a preventive medicine evaluation and management service, and the charges are itemized, combine the charges and pay only the preventive medicine evaluation and management service. Payment for the preventive medicine evaluation and management service performed on the same date of service includes the allowance for the developmental testing. A participating, preferred, or network provider cannot bill the member separately for developmental testing in this case.

If the developmental testing is performed independently, process it under code 96110.

Modifier 25 may be reported with a preventive medicine evaluation and management service to identify it as a significant, separately identifiable service from the developmental testing.  When the 25 modifier is reported, the patient's records must clearly document that a separately identifiable preventive medicine evaluation and management service has been rendered.