Wiki Sports Physical Requirements


Saginaw, MI
Best answers
I am a site billing and coding specialist for a family practice. We are having issues with the sports physical VS the yearly physical. When the patient comes in for a "sports physical" the provider is basically doing a yearly physical. This is where the problem starts, I need to code for what is documented, however the office staff already quoted a price for the "sports physical" which the price is way different than that price of the yearly. Some of our patients are only getting to the doctor when they need the sports physical, due to insurance or other hurdles. So the provider feels like they need to do a complete physical. Is that necessary? I code for what was done, not knowing its only suppose to be a sports physical, because the providers are doing the same exam for both. Is there a standard exam template that is used for sport physical exam? What are other practices doing to differentiate between the two. I have thought about sport physical clinics, but that is not my decision to make. I have done the research and checked numerous places and have found nothing useful on this. Is there a standard? How can we offer the sports physicals and stay in the guidelines of correct coding and billing regarding coding what is documented. I realize that we need to inform our front staff not to quote prices, that has already been done. Now I need to know if there is a sports physical standard exam template and where do I find it? My email is if anyone can offer guideance on this. Thank you.
This has been an issue that recently came up at our office. We have been told that for sports physicals, school clearance physicals & DOT physicals, we should be using the 99499 unlisted code UNLESS the patient is due for their yearly physical at that time, then we would use the regular physical codes. Our dept is currently in the midst of trying to build another SIM code so we can identify these types of visits so we can bill appropriately.
I know that some practices do/have done the following for sports physicals. This is kind of generic for this post.

1. The child must be a patient of the practice and seen regularly for their age.
2. The patient must have been seen with in the last six months.
3. Sports physicials would be completed as the needed paperwork states, and not a complete physical (as patient was seen within last six months).
4. A specific code titled "SPORTS" was built in and would then be entered into the computer for billing documentation, which had a fee that was agreed upon by all providers. An example would be $25. All sports physicals would be $25.
5. Parents were informed up front (when making appt) of the "rules" for a sports physical. They were told that it was XX dollars and that the sports physical would not be billed to insurance, and all of the above. When they arrived to the office, they were given a document that they signed stating the same as above.

This may not be the absolute best way to do sports physicals (or DOT, executive physicals) but the above worked for several offices that I know of. Of note, the offices I know of, validated this practice with their major insurance carriers and none of them had a problem with this as a "sports" or "DOT", etc, physical was not a covered service - if that is the only reason the patient came to the office.

If the patient came in for a sports physical and during the visit, the physician found something that needed treated, the sports physical was not billed and an age appropriate visit was billed. Sports paperwork may or may not have been filled out at this type of visit then, depending on what the medical issue was. This practice saved a lot of paperwork, denials and trying to collect from guardians later one. These type of physicals were paid at TOS.

And just FYI, the offices I know of that did this, those patients probably got the same level of care from the provider that any other child got when having a regular well-child visit.
sports physicals

I work for a larger clinic system, it is our practice we charge a low level office visit for sports physicals, DOT's, and the like. If our provider were to do a yearly physical with it, we would split bill it with the appropriate preventative code.
As far as template to use for the sports physical, that I have never heard of or seen. Hope that helps.
Jeff Parriott CPC; CPC-H