Provider Alert! Update: Reimbursement Code for Sports and Camp Physicals

As spring training and sports begin, it’s an ideal time to ensure that all members are receiving their Texas Health Steps check ups timely. Texas Children’s Health Plan wants to remind our pediatric providers about sports physicals as value-added services.

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 delivered 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, providers are encouraged to determine if  child is due for a Texas Health Steps check up also.

The checkup including all of the required Texas Health Steps components should be completed, as well as the sports physical.

Effective: For dates of service beginning January 1, 2017

As a value added service to CHIP and STAR Members under 21, Texas Children’s Health Plan will reimburse code 97169 – Athletic Training Evaluation, low complexity. This code is only reimbursed for sports and camp physicals when a member has also had a THStep or well child visit within the previous 12 months. Code 97169 will be the only code that is accepted for reimbursement, use of any other Athletic Training Evaluation code such as 97170-97172 will be denied). This replaces previous code 97005 which was discontinued 12/31/16.

Texas Children’s Health Plan will continue to pay $29.40, which is a flat rate of $30 less the 2% reduction that was previously paid for 97005. No other modifier will be required for this service. If you need further clarification, please contact your Provider Relations Manager or call the Provider Relations telephone line at 1-800-731-8527.