Great News! Community First Health Plans continues its value-added benefit for STAR, STAR Kids, and CHIP members. Members seeking a sports physical and/or back-to-school physical will be able to obtain this service from their assigned Primary Care Physician (PCP) or an In-plan Provider that also renders THSteps visits. Effective January 1, 2017.

General Requirements:

  1. One sports physical and one back-to-school physical may be billed once every twelve (12) months (allowable for any SSI, STAR/STAR Kids or CHIP member: 18 years of age or younger).
  2. The sports physical and back-to-school physical may be performed with a THSteps visit or an acute care visit. IMPORTANT: Separate claims with appropriate CPT codes and Diagnosis codes must be submitted for each type of visit if rendered on the same day.
  3. If a sport physical, back-to-school physical and/or THSteps visit is performed by a provider other than the member’s assigned PCP, the provider must submit copies of both exams and related diagnostic lab work to the member’s PCP for inclusion in the member’s medical record.

Guidelines for billing:

  1. Diagnosis code Z02.5 is the only valid code to submit for a sports physical or back-to-school physical.
  2. Sports physicals and back-to-school physicals must be billed on CMS 1500 format.
  3. For a sports physical, procedure code 97169, 97170, 97171 (evaluation and form completed) or 99080 (form only completed) may be billed.
    • RATES:
      • 97169, 97170, 97171 – $30.00 if completed by a physician; $27.60 if completed by NP or PA
      • 99080 – $15.00 if completed by a physician; $13.80 if completed by NP or PA
  4. For a back-to-school physical, procedure code 99382-99385 or 99392-99395 may be billed.
    • RATES:
      • 99382-99384/99392-99394 – $68.25 if completed by a physician; $62.79 if completed by an NP or PA
      • 99385 or 99395 – $47.57 if completed by a physician; $43.76 if completed by an NP or PA

Please contact your Community First Network Provider Representative (210-358-6294) if you have any questions regarding this value added benefit.

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