cjorr65
Contributor
I need clarification please. Management just sent an email instructing us that the providers do not have to document the presence of a chaperone to use this code. Has this rule changed?
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Hi, we have the same directive.
cjorr65
Contributor
one of our coders told management that the rule changed in December, so they said it was no longer necessary to document the presence of chaperone. I was not able to find any supporting documentation. That is why I am posting here- does anyone have supporting doc?
I recall hearing/reading recently that during some type of Q&A or webinar, it was stated a pelvic exam without a chaperone may still use 99459. In fact, all along, there have been parties claiming 99459 could be used without a chaperone, but that was not my interpretation of how the code was initially valued. I know ACOG specifically states
Regardless, I have advised my team that unless we can find actual official guidance otherwise, we are still using only when there is a female pelvic exam with a chaperone documented. If I come across the recent advice, I will add it here.
Regardless, I have advised my team that unless we can find actual official guidance otherwise, we are still using only when there is a female pelvic exam with a chaperone documented. If I come across the recent advice, I will add it here.
No unfortunately. I looked through my emails and we received the directive last fall from leadership.
nielynco
True Blue
On April 6, 2024 the following Q&A was posted by the CPT Assistant:
| May CPT code 99459 be reported if the patient declines the need for a chaperone for a pelvic examination during an E/M visit? | CPT add-on code 99459, Pelvic examination (List separately in addition to code for primary procedure), was established to capture the additional practice expense resources required during a pelvic examination as part of the service for preventive medicine or the evaluation and management services for those who require pelvic examinations. While the Practice Expense Subcommittee of the RUC noted that the 4 minutes of clinical staff time for 99459 captures the time associated with chaperoning a pelvic exam for a typical patient, it should be noted that the use of a chaperone is not a requirement for reporting 99459 per CPT coding guidelines. The specialty societies' supporting evidence identifies the best clinical practices for a chaperone to be present for all breast, genital, and rectal examinations regardless of the sex or gender of the person performing the examination. There are no additional clinical activities recommended as the physician work of performing the pelvic exam is included in the primary code. As far as documentation requirements are concerned, please note that this is outside the scope of CPT coding and may be better redirected to your individual third-party payer(s) or to the relevant specialties for best practices and other documentation-related concerns. |
what should the documentation state since some commercial payer don't have guidelines on it?
nielynco
True Blue
Is there some problem with just indicating a chaperone was present? This has been debated since the inception of this code. In my opinion, it was valued based on the use of the pelvic pack and a chaperone so it should be documented (a simple statement should suffice). This statement also protects a male physician from any risk issues. What you must make sure, however, is to have documented the need for a pelvic exam in the first place during the course of the E/M visit.