CPT Code 99459: New Billing Rules and Reimbursement Changes for 2025

CPT code 99459 was introduced on January 1, 2024, and serves as an add-on code for pelvic examinations conducted alongside an E/M service. This code accounts for the practice expenses related to the pelvic exam, which includes the time of clinical staff and necessary supplies.

As an add-on code, 99459 must be reported in conjunction with a primary E/M code and cannot be billed independently.

Important Notes:

• 99459 is an add-on code; it cannot be billed independently and must be associated with a primary E/M service.
• It encompasses staff time, equipment, and disposable supplies, but does not include the physician’s work.
• Adequate documentation is essential to validate its use and ensure compliance.
• The pelvic examination must be deemed medically necessary or included as part of a preventive visit.
• Coverage may differ by payer, so it is advisable to review insurance policies in advance.

CPT Code 99459 Description

The intent of CPT code 99459 is to account for the additional practice expenses incurred during a pelvic examination. This encompasses the costs of supplies such as speculums, gowns, and drapes, as well as the clinical staff’s time for activities like chaperoning the patient throughout the examination.

This code does not encompass the physician’s work during the examination; it solely addresses the ancillary costs associated with the procedure.

Applying CPT Code 99459

CPT code 99459 is designated as an add-on code for outpatient or well-patient office visits, making it applicable in various situations such as screening and annual wellness visits when the examination is warranted. Given that it is an add-on code, it cannot be billed independently and must be reported alongside a primary service code on the same date of service.

This code may be added to a specified range of services, which includes both new and established patient visits, consultations, and wellness examinations, in accordance with CPT coding regulations. Typically, Medicare and private insurers adhere to this list; however, Medicare may expand it to include additional G codes for annual wellness visits or “Welcome to Medicare” examinations. As the guidelines for coverage and coding regulations evolve, healthcare providers must remain updated to guarantee accurate billing and compliance.

Situation:

A 16-year-old female patient presents with irregular menstrual cycles. After reviewing her medical history, the physician concludes that a pelvic examination is warranted. A female nurse is present to serve as a chaperone.

• Billing: Primary E/M code: 99203
• (New patient office visit, low complexity)
• Add-on code: 99459

(To account for the extra practice costs associated with the pelvic examination) Key Considerations: Obtaining consent is crucial, particularly for minors. The provider should clarify the purpose of the examination and ensure the patient’s comfort. Should the patient refuse the examination, this should be documented, and code 99459 would not be billed.

Appropriate Usage of CPT Code 99459

CPT code 99459 is applicable when a pelvic examination is conducted as part of an E/M service within an office environment (Place of Service 11). CPT code 99459 is utilized when a pelvic examination is performed as part of an E/M service in an office context, frequently managed through specialized physician billing services. The following E/M service codes may be reported alongside CPT code 99459:

• Office or Other Outpatient Visits for New Patients: 99202–99205
• Office or Other Outpatient Visits for Established Patients: 99212–99215
• Consultation Codes: 99242–99245
• Preventive Medicine Services
• New Patients: 99383–99387
• Established Patients: 99393–99397

For Medicare patients receiving preventive visits, the relevant HCPCS codes are:

• G0402: Initial preventive physical examination; face-to-face visit, services are restricted to new beneficiaries within the first 12 months of Medicare enrollment.
• G0438: Annual wellness visit; encompasses a personalized prevention plan of service (PPPS), initial visit.
• G0439: Annual wellness visit; encompasses a personalized prevention plan of service (PPPS), subsequent visit.

However, there is currently no official guidance regarding the reporting of CPT code 99459 in conjunction with these specific HCPCS codes.

CPT 99459 Billing Guidelines for 2025

To ensure payment, adhere to the following 2025 guidelines:

Pair it with an appropriate E/M code:

Thoroughly document:

• The rationale for performing the pelvic exam, details regarding the chaperone (if applicable), and the involvement of supplies and staff.

Review payer-specific regulations:

• Certain insurance plans may bundle this code with an E/M visit. Medicare may impose different coverage restrictions.

Prevent billing mistakes:

• 99459 cannot be billed as an independent service. Ensure it is medically necessary.

Documentation Requirements

Precise documentation is essential when reporting CPT code 99459. The medical record must explicitly indicate that a pelvic examination was conducted as part of the E/M service. If a chaperone was present during the examination, record the chaperone’s name, role, and the duration of their involvement.

If a chaperone was offered but declined by the patient, this should also be documented. Proper documentation guarantees adherence to billing regulations and substantiates the medical necessity of the service rendered.

Situation: A 45-year-old woman presents for a well-woman examination. The provider conducts a comprehensive preventive examination, including a pelvic exam. A chaperone is present during the examination to ensure the comfort of the patient.

Billing: Primary E/M code: 99386 (Preventive visit for new patient, aged 40–64) Add-on code: 99459 (To capture the cost of supplies and staff time during the pelvic exam)

CPT 99459 Reimbursement

As a practice expense only code, CPT 99459 is assigned a value of 0.68 relative value units (RVUs) for non-facility settings. This valuation accounts for approximately 4 minutes of clinical staff time required to accompany the pelvic exam, as well as the cost of supplies such as a speculum. It is important to note that this code does not encompass physician work RVUs, as it pertains solely to practice expenses.

When submitting a claim for CPT 99459, it must be listed separately and in addition to the primary E/M service code. Ensure that the primary procedure code accurately reflects the E/M service, and that CPT 99459 is appropriately linked to that primary code.

Be mindful that payer policies can differ, and certain insurers may impose specific regulations regarding this add-on code; therefore, it is advisable to verify with individual payers to guarantee compliance and appropriate reimbursement.

Labor Reimbursement in CPT Code 99459 

CPT 99459 lacks a physician work component, meaning that physicians will not receive reimbursement for their time spent performing the exam under this code. Instead, it is designed to cover overhead costs such as staff time and equipment usage. Billing for equipment that was not utilized would be challenging to substantiate. There is ongoing discussion regarding the interpretation of staff time within this code.

Some argue that the requirement for a chaperone, which is mandated in certain states and medical practices, falls under this code. Others contend that the staff time pertains to activities such as assisting the patient with undressing, getting onto the exam table, and positioning, which collectively take at least 4 minutes.

Medicare’s final regulations reference the term “chaperone,” yet this appears to be merely one of the elements influencing the assessment of staff time rather than a stipulation for a chaperone’s presence.

Staff participation in these examinations extends beyond mere attendance; it includes assisting with patient preparation, providing support during the examination, and overseeing post-examination responsibilities such as specimen processing and cleanup. However, the precise methodology for calculating this time remains ambiguous.

It is noteworthy that the reimbursement for these four minutes of staff time is relatively minimal when compared to the expenses associated with equipment and supplies under this code, particularly in environments like Hospital Billing Services where adherence to compliance and resource management is essential.

Conversations surrounding reimbursement and coding frequently neglect wider healthcare implications. In jurisdictions where a chaperone is mandated for certain medical examinations, adherence to legal requirements is crucial. From both medical and legal standpoints, documenting whether a chaperone was offered, accepted, or present is increasingly significant. Nevertheless, there is no indication that a chaperone will become a necessary element for billing CPT code 99459.

Clinical Implications

Medicare’s final regulations reference the term “chaperone,” yet this appears to be merely one of the elements influencing the assessment of staff time rather than a stipulation for a chaperone’s presence.

Staff participation in these examinations extends beyond mere attendance; it includes assisting with patient preparation, providing support during the examination, and overseeing post-examination responsibilities such as specimen processing and cleanup. However, the precise methodology for calculating this time remains ambiguous.

It is noteworthy that the reimbursement for these four minutes of staff time is relatively minimal when compared to the expenses associated with equipment and supplies under this code, particularly in environments like Hospital Billing Services where adherence to compliance and resource management is essential.

Discussions regarding reimbursement and coding frequently neglect wider healthcare issues. In states where a chaperone is mandated for certain medical examinations, adherence to legal requirements is crucial. From both medical and legal viewpoints, documenting whether a chaperone was offered, accepted, or present is increasingly significant. However, there is no indication that a chaperone will become a necessary element for billing CPT code 99459.

Reporting CPT Code 99459 With Modifier 25 

Is CPT code 99459 reportable alongside an E/M service when modifier 25 is utilized? For instance, if a patient undergoes an E/M visit and a cystoscopy on the same day, it remains uncertain whether 99459 can be reported with modifier 25, provided that medical necessity and procedural performance are satisfied. There is no explicit prohibition against this combination, but medical necessity remains paramount. If a pelvic examination is postponed until the cystoscopy and there is a legitimate reason to conduct an E/M service during the procedure, it is generally acceptable to include it in the claim.

Non-Facility Codes Relevant to Add-On CPT Code 99459

To Conclude!

CPT code 99459 enables providers to account for practice expenses related to pelvic exams during E/M services. To utilize it correctly, providers must associate it with the appropriate primary E/M codes, document comprehensively, and adhere to payer regulations. It is essential to remain informed about coding updates to guarantee precise billing and reimbursement.

As coding regulations evolve, healthcare professionals should keep abreast of changes through training, expert guidance, and professional resources. Proper use of CPT code 99459 enhances operational efficiency and quality care in women’s health.