Sports Physicals

There is no specific CPT code assigned for kids presenting for a pre-participation sports exam. If you’ve been around for a while, you are familiar with this conundrum.

Key Factors in Code Selection

How you go about reporting this (or not) is going to depend on a few key factors:

1. Who is the payer?
   1. Texas Medicaid?
   2. Medicaid Managed Care?
   3. Commercial Payer?
   4. ISD Contract?
2. Is sports exam the sole reason the patient is presenting?
3. Is this exam part of a covered well child check or preventive exam?

As you can see, this is a very payer-specific coverage scenario.

“How should a pre-participation school sports physical be reported and reimbursed under this member’s plan?” question should be a part of the verification process.

Texas Medicaid states that pre-participation sports exams are not a covered benefit. That said, several Medicaid Managed Care plans do provide coverage and guidance on their web pages.

We have created a sample grid that may help you decide how to handle these exams.

School Pre-Participation Sports Exams: CPT Possibles by Payer

Payer / Scenario	Possible Coding	Notes / Considerations
Commercial Payers	Preventive Medicine E/M (99381-99397)	Appropriate when the encounter meets the requirements of a preventive medicine service and includes the elements of a wellness examination. Coverage varies by plan.
Commercial Payers (When Sports Physical is Sole Purpose of Visit)	Internal/self-pay sports physical code or cash-pay process	Many commercial plans consider sports physicals non-covered unless performed as part of a covered preventive visit.
Texas Children’s Health Plan	97169	Texas Children’s has published guidance indicating reimbursement for pre-participation sports physicals using 97169. This is TCHP payer-directed reporting guidance.
Community First Health Plans	97169	Community First has similarly published guidance directing use of 97169 for sports physicals. Provider reporting should follow payer instructions when submitting claims to Community First.
School District-Sponsored Events	No claim submitted or contracted event billing	Some providers perform mass sports physical events under a contract with a school district rather than billing insurance.
Texas Medicaid Traditional Medicaid – Non-Covered Service	Verify current Texas Medicaid Managed Care payer guidance	Sports physicals may be reported differently depending on whether the service qualifies as an EPSDT/THSteps preventive service versus a stand-alone sports clearance exam. Benefit verification is recommended.
Medicare	Generally, not applicable	School sports physicals are rarely applicable to the Medicare population.
Athletic Training	97169 (when specifically directed by payer)	Although many coding professionals question whether 97169 was intended for school sports physicals, some payers have expressly instructed providers to bill in this manner.
Self-Pay Patients	Organization-specific sports physical fee	Common when no insurance benefit exists for the sports clearance examination.

Compliance Considerations

Best Practice: Follow published payer guidance when a payer has specifically instructed providers to report the service using a particular code.

Documentation Recommendation:

Clearly document that the encounter was a pre-participation athletic clearance examination and whether the service was performed as:

• A preventive wellness visit
• A stand-alone sports physical
• A payer-directed service requiring specific reporting instructions

Final Thought

In the end, whether we use an age-appropriate physical exam CPT code, an E/M (Champus and TriCare), or the Athletic Training CPT code 97169, we need to be diligent to report what each payer will (or won’t) pay for and bill accordingly.

Compliance Pearl: If you use 97169 solely because a payer specifically instructs providers to do so, I would retain a copy of that payer guidance. During an audit, the strongest defense is often, “We followed the payer’s published billing instructions for this plan.” That is much easier to defend than relying solely on anecdotal guidance.

Resources

Medexpertservices Article (external link)

ACP: Coding Review: Preparticipation Physical Evaluations | AAP Pediatric Coding Newsletter | American Academy of Pediatrics (external link)

Texas Children’s 97169 Article (external link)

Community First 97169 Article (external link) 

Outsource Billing Strategies:  Sports Physicals (external link)