Is a teen well visit or sports physical covered by insurance?
Usually yes, once a year, at no cost in network. A teen well visit (code 99394) is the yearly checkup for a patient aged 12 through 17, and the sports clearance form normally gets signed at that visit. What plans do not pay for is a separate appointment whose only purpose is the paperwork.
Once a year
Preventive, form signed at the visit
Form is included
There is no sports physical code. The exam bills as the yearly checkup, and the form gets signed while the family is already in the chair.
Form only visit
An August appointment just to sign a form is not preventive care. Most plans pay nothing, so it is billed to the family or reported as 99080.
The EOB goes home
The plan's statement goes to the policyholder, so anything billed at a teen visit shows up at home. Worth raising with the family up front.
Two weeks out
Sports season fills the schedule. Running checks two weeks ahead shows plan status, deductible left and copay before the August rush hits the desk.
What would a real check show for this patient's 99394?
Pick a sample plan and type your fee. This is the visibility a real-time check gives the desk for every actual patient, in under a second.
Eligibility readout · 99394
Sample- Coverage
- Active, teen checkup at $0 in network
- Frequency
- One teen checkup per plan year, none used
- Patient share
- Type your fee to see it
Estimate from a sample plan. A real check reads the actual plan in under a second.
When 99394 is the right code
- Patient is 12 through 17 on the visit date
- The teen is established at this practice
- It is the yearly checkup, not a complaint
- Sports or school form signed at that same visit
Documentation payers expect
Expect payers to look for age, a full exam, screenings and counseling in the record. If the appointment exists only to complete a form, code it that way instead of calling it preventive.
Why teen physicals get denied
What happens after the sports physical
Clearance is rarely the last line on the claim. The HPV series (90651), a Tdap booster (90715) and the meningococcal shot (90734) come due in this age band, each carrying a counseling shot fee (90460). A mood questionnaire (96127) can land on the same claim, and anything the exam turns up becomes a problem visit, often 99213, with its own copay. Families who never argue about it heard the plan numbers before the appointment.
99394, quick answers
Does insurance cover a sports physical?
Usually, when it is done as the teen's yearly checkup. Most plans cover 99394 as preventive care at 100% in network and the form is signed at that visit.
What if the teen already had a checkup this year?
Then the preventive benefit is used, and a second exam for the sports form is normally the family's cost. Many practices set a flat fee for it.
Does a walk in clinic sports physical count against the plan?
On most policies, yes. That spring exam at the school clinic is exactly why the August visit at the pediatrician gets denied.
Does Medicare pay for a teen physical?
No. Medicare pays its wellness visits under separate G codes and does not recognize 99394, which is a moot point for a 12 to 17 year old anyway.
How far ahead should the desk verify for sports season?
Two weeks is enough, and each patient on the schedule comes back in under a second with plan status, remaining deductible and out of pocket, and any referral or prior authorization flag the payer sends. First month free, then $2.50 a check.
More questions? Schedule 15 minutes with us and bring your toughest plan.
Clear the whole sports physical rush before August starts.
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Related: 99393 · 99384 · 99080
CPT is a registered trademark of the American Medical Association. This page is Valian's own plain-English summary for front-desk teams, not official CPT descriptor text, and is not billing or clinical advice. Coverage patterns are common plan behaviors; every plan differs. Verify benefits before the visit.