MedicaidCoverageHigh impact
Medicaid Coverage of Sports Physicals, Effective August 14, 2023
Maryland Medicaid·MD · Pediatrics, Family Medicine, General Practice +1 more·Provider Transmittal
Effective date
Aug 14, 2023
We identified it
Jun 20, 2026
Summary
Maryland Medicaid now covers sports physicals provided in School Based Health Centers (SBHCs) by physicians, nurse practitioners, and physician assistants, effective August 14, 2023. Billing teams must use CPT 99212 with ICD-10 Z02.5, Place of Service Code 03, and either bill at the FFS rate of $61.84 (non-FQHC SBHCs) or include modifier T1015 (FQHC-sponsored SBHCs). Coverage is limited to one sports physical per benefit year for students ages 6-18.
Action Required
By September 14, 2023: Billing team must update billing system and encounter forms to enable billing for sports physicals in SBHCs only. (1) Configure CPT 99212 with primary ICD-10 diagnosis Z02.5 for non-FQHC SBHCs at $61.84 reimbursement. (2) For FQHC-sponsored SBHCs, configure CPT 99212 to require modifier T1015 with Z02.5 diagnosis code. (3) Set Place of Service Code 03 (school) as required field for all sports physical claims. (4) Implement system rule: one sports physical per benefit year per student, ages 6-18 only. (5) Enable same-day billing of sports physicals with well-child exams (99383, 99384) when both performed, requiring modifier 25 on well-child codes and ICD-10 codes from Z00/Z02 series. (6) Train billing staff and providers on new codes, modifiers, and documentation requirements. (7) Update claim submission instructions for HealthChoice MCO compliance. Failure to implement correctly will result in claim denials and missed revenue.