Pre-participation physical exams, often called “Sports Physicals,” are typically required by state law and by school districts, which provide specific forms to be completed by both patient/family and physician. These forms include documentation of any concerns or findings along with the physician’s recommendations regarding sports participation and, typically, are valid for a year. These visits are often described as “clearance” although there is movement towards risk stratification for eligibility to play sports, since risk persists despite such “clearance.”
Complete guidelines for the evaluation of athletes is beyond the scope of this handbook, but are available. Routine EKGs haven’t been cost-effective for identification of previously-unknown conditions during screening. Similarly, there is no role of routine urine and blood tests. Pre-participation forms often require evidence of vaccination, although many schools may also have these records and parents may have to supply that information separately. If referrals or further studies are required before clearance, and the athlete isn't established with you, you may recommend a separate routine office visit with their primary care physician. If the athlete is established at your practice, you can order these without an office visit (simply include an appropriate ICD-10 for any signs/symptoms when you order the CPT code for the particular study or make the referral). You may then consider reviewing the results with the patient during a routine office visit and completing the form accordingly.
Many practices charge an upfront flat-fee for pre-participation evaluations and don’t code or bill through insurance at all. In this case, no ICD-10 codes or CPT codes would be placed (unless there’s a problem). The paper forms brought by the athlete from school would simply be filled out and returned after being scanned into the chart. If your practice does charge insurance for the visit, use the ICD-10 code Z02.5: Routine sports physical exam. You could use 99212, since insurance is unlikely to cover a higher code, unless abnormalities are found.
If the sports physical is performed along with a routine pediatric preventive care visit, the codes Z00.129 and Z00.121 Well child without or with abnormal findings would be appropriate, with the additional code Z02.9 Administrative encounter, to indicate work above and beyond the well-child exam. You would then use the normal preventive care CPT codes 99393-99395, and include 99080 (for special reports such as insurance forms), but this approach may result in rejected claims. It’s because of these challenges that many practices simply charge an out-of-pocket flat-fee for the sports physical or simply “waive” the sports physical, if performed during a pediatric preventive health visit, since it doesn’t typically take much additional time beyond the preventive visit.