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.