add on code 99459

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desireewhite185@yahoo.com

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Hello,
I am looking for some advice on when to use add on code 99459, pelvic examination. The book shows it can be used in conjunction with 99202-05, 99212-15, 99242-45, 99383-87, 99393-99397. Our office does a lot of pelvic exams, so can we use this add on code every time? Any certain criteria?
Thanks, Des
 
desireewhite185@yahoo.com said:
Hello,
I am looking for some advice on when to use add on code 99459, pelvic examination. The book shows it can be used in conjunction with 99202-05, 99212-15, 99242-45, 99383-87, 99393-99397. Our office does a lot of pelvic exams, so can we use this add on code every time? Any certain criteria?
Thanks, Des
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We just did a quick explanation of the intent of 99459 in the January issue of the OB/GYN Coding Alert: Per the Federal Register:

Pelvic Exam (CPT code 99459)
In September 2022, the CPT Editorial Panel created a new CPT code for reporting a pelvic exam – CPT code 99459. The specialty societies noted that reimbursement for the work would be captured with the problem-oriented E/M code billed for the visit. The CPT Editorial Panel agreed, thus the new code is a practice expense only code that captures the direct practice expenses associated with performing a pelvic exam in the non-facility setting. CPT code 99459 (Pelvic Exam) captures the 4 minutes of clinical staff time associated with chaperoning a pelvic exam. We proposed the RUC-recommended direct-PE inputs for CPT code 99459 without refinement. As a PE-only service, the RUC did not recommend and we did not propose a work RVU for this code.

The purpose is to reimburse the practice for the use of a chaperone, not to reimburse for the collection per se (as with Q0091). It remains to be seen if commercial payers will reimburse on this code and if a chaperone was not used during the Pap collection I would not use this code at all.
 
I am confused as well, as unfortunately, the coding guidelines says that it can be coded with the prevent visits and not just the problem visits. Are we to assume if a patient sees their PCP for a prevent visit and the provider decides to perform a pelvic exam, would this then apply to the use of the CPT code 99459. Thanks
 
Does anyone have thoughts on whether this code can also be applied to IUD insertions, endometrial biopsies, etc. that are performed in the Gyn office?
 
colebk said:
Does anyone have thoughts on whether this code can also be applied to IUD insertions, endometrial biopsies, etc. that are performed in the Gyn office?
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No it may not. It is only for use of a chaperone for a the stated purpose of a female pelvic exam that is done yearly. Or rather let me put it another way. A pelvic exam would be integral to an IUD insertion, endometrial BX, etc as part of the procedure. The staff "helper" is already there to assist so this new code would not apply. If the patient presents with a complaint that requires a full pelvic exam or is being seen for her yearly pelvic exam, you could bill this code if a chaperone was required during the time of this exam. I and would add that this presence would need to be documented in the record.
 
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lddavis said:
I am confused as well, as unfortunately, the coding guidelines says that it can be coded with the prevent visits and not just the problem visits. Are we to assume if a patient sees their PCP for a prevent visit and the provider decides to perform a pelvic exam, would this then apply to the use of the CPT code 99459. Thanks
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To repeat. If the patient is having her annual pelvic exam and a chaperone is used during this exam, this code may be reported. It pays only the "practice expense" amount that is involved in having this extra person in the room. Many female physicians do not utilize a chaperone so the expense would not be there. Most male provider do have one present. Also keep in mind that just because there is a code available is no guarantee of payment. Medicare lists this code as "active" on their payment files, but it remains to be seen if they will reimburse, especially if you are also billing Q0091 with this code. However, I think it is too early to tell. The effective CCI edits for January 1, 2024 do not include this new code, but next quarter it might after Medicare sees how often it is being billed.
 
I see the book does also show, it can be billed at time of E/M codes. Let's say a patient comes in for vaginal d/c, and the physician does a pelvic exam/swab and notes using a chaperone. We should be able to use it then, don't you think? Like you said, who knows if the insurance will pay or not, but..
Thank you very much!
 
Good Afternoon I was asked today my Primary Care Group if this code only applies to female patients? If a female provider utilizes a Chaperone in a pelvic exam for a Male patient for example during an STD check/swab or Prostate exam can she utilize this code as well? There is no definition of Male or Female on the Encoder.
 
desireewhite185@yahoo.com said:
I see the book does also show, it can be billed at time of E/M codes. Let's say a patient comes in for vaginal d/c, and the physician does a pelvic exam/swab and notes using a chaperone. We should be able to use it then, don't you think? Like you said, who knows if the insurance will pay or not, but..
Thank you very much!
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My understanding of this new code is that 99459 would be appropriate (along with 99202-99215) in the situation you describe. 99459 is a practice expense only code to reimburse for chaperone time as well as supplies (like speculum).
ACOG has some information about this code here https://www.acog.org/news/news-articles/2023/10/acog-win-cms-increases-payment-for-pelvic-exams
In the ACOG article, there is a link to their payment policy and advocacy portal that contains even more information if you sign up.
 
nscrldy20 said:
Good Afternoon I was asked today my Primary Care Group if this code only applies to female patients? If a female provider utilizes a Chaperone in a pelvic exam for a Male patient for example during an STD check/swab or Prostate exam can she utilize this code as well? There is no definition of Male or Female on the Encoder.
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While I have not seen anything in the code itself that restricts it to female patients, it does state "pelvic exam" which to me means an exam in which the clinician is examining the vulva, vagina, cervix and/or uterus. I would not call a prostate exam a "pelvic exam". The intention of this code championed by ACOG was for female patients. The Codify additional information for this code would indicate to me it is not appropriate in the examples you provide.
 
csperoni said:
While I have not seen anything in the code itself that restricts it to female patients, it does state "pelvic exam" which to me means an exam in which the clinician is examining the vulva, vagina, cervix and/or uterus. I would not call a prostate exam a "pelvic exam". The intention of this code championed by ACOG was for female patients. The Codify additional information for this code would indicate to me it is not appropriate in the examples you provide.
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To piggyback on what @csperoni stated that this code would not be appropriate to bill for a prostate exam. EncoderPro for Payers has the following lay person description of 99459:

A pelvic exam is performed in addition to an evaluation and management service. The physician places two lubricated and gloved fingers inside the vagina to palpate the cervix, uterus, and ovaries while using the other hand to gently palpate the top of the uterus with pressure on the abdomen, noting the organs' size, shape, and/or any abnormality.​

Clearly this description indicates that this is code should only be billed for a patient with any female internal organs. As a side note it could be used on a F to M transgendered patient who still has internal female reproductive organs.
 
desireewhite185@yahoo.com said:
I see the book does also show, it can be billed at time of E/M codes. Let's say a patient comes in for vaginal d/c, and the physician does a pelvic exam/swab and notes using a chaperone. We should be able to use it then, don't you think? Like you said, who knows if the insurance will pay or not, but..
Thank you very much!
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I believe I answered this in one of the threads. This code would apply for any pelvic exam performed for a problem or a routine annual pelvic. It just would not be billed separately if the patient is presenting for a procedure that also involved a pelvic exam to be done prior to performing the procedure.
 
csperoni said:
While I have not seen anything in the code itself that restricts it to female patients, it does state "pelvic exam" which to me means an exam in which the clinician is examining the vulva, vagina, cervix and/or uterus. I would not call a prostate exam a "pelvic exam". The intention of this code championed by ACOG was for female patients. The Codify additional information for this code would indicate to me it is not appropriate in the examples you provide.
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You are quite correct. The code was championed by ACOG for female patients and if you look at the 2024 CPT Coding Changes book you will see that the clinical vignette describes a female, not male exam.
 
We bill as a hospital outpatient department. I have found no guidance on whether we would be allowed to code and bill the 99459. Does anyone have any insight?
 
HavaTwo said:
We bill as a hospital outpatient department. I have found no guidance on whether we would be allowed to code and bill the 99459. Does anyone have any insight?
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This question was addressed previously in this thread by @nielynco, this code is for use in non-facility settings. Additionally, the information from Elaine is also contained in an AAPC Ob-Gyn Coding alert titled CPT 2024 Update: Federal Register Clarifies Pelvic Exam Add-on Code. If you would like to see the actual regulatory guidance you can view it via this link to the Federal Register for the Medicare and Medicaid Programs: CY 2024 Payment Policies under the PFS. If you do a ctrl+F search for 99459 of this federal register rule you will find the same information cited above regarding the fact that this code is for non-facility setting providers.
 
I understand when to use the 99459, but my question is, how are providers supposed to document this so that we can bill it out? Do they just put a note in saying "____ was in the room with me during the pelvic exam." or something like that?
 
metzger130 said:
I understand when to use the 99459, but my question is, how are providers supposed to document this so that we can bill it out? Do they just put a note in saying "____ was in the room with me during the pelvic exam." or something like that?
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That would seem sufficient. My providers have been documenting chaperones for at least the last 18 years I've been working in gyn oncology.
Here are some examples of their wording:
FIRST LASTNAME was present the entire time of gynecological exam.
A chaperone was present in the examining room during all aspects of the physical examination FIRST LASTNAME.
 
My question doesn't really pertain to 99459 but, is a related topic. Provider only in the room. What code is used for a pelvic exam only with pap for commercial payers? No breast exam is usually done. Typically, it is a patient that has a physical done elsewhere but, is not comfortable with their male PCP doing a pelvic exam. We are not a GYN clinic. I was looking at S0612 but, I am under the impression this includes a breast exam. Since patients present for pap/pelvic only I have been using level 2 office visit as there is typically little MDM involved.
 
nielynco said:
We just did a quick explanation of the intent of 99459 in the January issue of the OB/GYN Coding Alert: Per the Federal Register:

Pelvic Exam (CPT code 99459)
In September 2022, the CPT Editorial Panel created a new CPT code for reporting a pelvic exam – CPT code 99459. The specialty societies noted that reimbursement for the work would be captured with the problem-oriented E/M code billed for the visit. The CPT Editorial Panel agreed, thus the new code is a practice expense only code that captures the direct practice expenses associated with performing a pelvic exam in the non-facility setting. CPT code 99459 (Pelvic Exam) captures the 4 minutes of clinical staff time associated with chaperoning a pelvic exam. We proposed the RUC-recommended direct-PE inputs for CPT code 99459 without refinement. As a PE-only service, the RUC did not recommend and we did not propose a work RVU for this code.

The purpose is to reimburse the practice for the use of a chaperone, not to reimburse for the collection per se (as with Q0091). It remains to be seen if commercial payers will reimburse on this code and if a chaperone was not used during the Pap collection I would not use this code at all.
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should i bill the 99395 with a modifier 25 and then the 99459? or not bother with any modifiers?
 
csperoni said:
That would seem sufficient. My providers have been documenting chaperones for at least the last 18 years I've been working in gyn oncology.
Here are some examples of their wording:
FIRST LASTNAME was present the entire time of gynecological exam.
A chaperone was present in the examining room during all aspects of the physical examination FIRST LASTNAME.
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hey csperoni
would you bill the annual with a mod 25 and then then the chaperone code?
 
Korbc said:
hey csperoni
would you bill the annual with a mod 25 and then then the chaperone code?
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Korbc said:
should i bill the 99395 with a modifier 25 and then the 99459? or not bother with any modifiers?
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99459 is specifically an add on code to office E&M, preventive and consult codes. Therefore, mod -25 on the visit is NOT required. That is the NCCI guideline.
It is possible that some commercial carriers will create an internal guideline that may either not pay for 99459 at all, or require a modifier.
 
csperoni said:
99459 is specifically an add on code to office E&M, preventive and consult codes. Therefore, mod -25 on the visit is NOT required. That is the NCCI guideline.
It is possible that some commercial carriers will create an internal guideline that may either not pay for 99459 at all, or require a modifier.
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whops! didn't actually look at in the book yet and didn't realize it was an add on code, I just assumed a separate e/m by itself. Thanks csperoni!
 
We are documenting a chaperone is present - I do have some Female providers who do not use a chaperone , was under the impression you wouldn't bill , however I have read that in the CPT changes there is no indication /statement that a chaperone is required in order to bill this code- thoughts? Side note- we have received payment
 
smihm said:
We are documenting a chaperone is present - I do have some Female providers who do not use a chaperone , was under the impression you wouldn't bill , however I have read that in the CPT changes there is no indication /statement that a chaperone is required in order to bill this code- thoughts? Side note- we have received payment
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ACOG has specifically advised there must be a chaperone used and documented to code 99459, although I do not see this requirement in the CPT description. In one of my prior replies, I included the links to the ACOG guidance.
csperoni said:
My understanding of this new code is that 99459 would be appropriate (along with 99202-99215) in the situation you describe. 99459 is a practice expense only code to reimburse for chaperone time as well as supplies (like speculum).
ACOG has some information about this code here https://www.acog.org/news/news-articles/2023/10/acog-win-cms-increases-payment-for-pelvic-exams
In the ACOG article, there is a link to their payment policy and advocacy portal that contains even more information if you sign up.
Click to expand...
 
csperoni said:
ACOG has specifically advised there must be a chaperone used and documented to code 99459, although I do not see this requirement in the CPT description. In one of my prior replies, I included the links to the ACOG guidance.
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The reason for this is that the code was valued specifically based on the use of a chaperone. The relative values are based on the work of a chaperone and this is also specifically stated in the federal register that published this years relative values for new services.
 
https://codingintel.com/billing-pap-smear/

Check out this link above. This states no chaperone is needed.
Something in this articles confuses me though, It says, "If the patient presents for a preventive medicine service, the pelvic exam is part of the age and gender appropriate physical exam, as described by CPT® codes in the 99381—99397 series of codes."
But then below it says, "CPT introduced this code in 2024 as an add-on code to new and established patient visit codes 99202–99205, 99212–99215, consultation codes 99242–99245 and preventive medicine codes. 99383–99397, 99393–99397"
  • Use the code for both preventive and problem visits
So, should we bill it with preventive visits? I just started to utilize this code and the Q0091 for our office visits, with pelvic exam and/or Pap smears. We will see how insurances process this.

Thank you!!
 
desireewhite185@yahoo.com said:
https://codingintel.com/billing-pap-smear/

Check out this link above. This states no chaperone is needed.
Something in this articles confuses me though, It says, "If the patient presents for a preventive medicine service, the pelvic exam is part of the age and gender appropriate physical exam, as described by CPT® codes in the 99381—99397 series of codes."
But then below it says, "CPT introduced this code in 2024 as an add-on code to new and established patient visit codes 99202–99205, 99212–99215, consultation codes 99242–99245 and preventive medicine codes. 99383–99397, 99393–99397"
  • Use the code for both preventive and problem visits
So, should we bill it with preventive visits? I just started to utilize this code and the Q0091 for our office visits, with pelvic exam and/or Pap smears. We will see how insurances process this.

Thank you!!
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This new code is for practice expense only, not physician work. Therefore the exam work by the physician is already covered in the E/M he/she is billing for. I would take their assessment that no chaperone is needed to bill the code with a grain of salt. ACOG got the code added to CPT and ACOG's interpretation is the one you should go with.
 
It is interesting to hear the discussions about a chaperone. I listened to the 2024 CPT symposium regarding the use of this code and a chaperone was never mentioned. The speaker from the CPT symposium stated that anytime a pelvic exam is performed, well or sick visit, you can add this code due to the fact that it is a practice expense only. Just cannot be added with a procedure because a pelvic is included with the procedure. Thank you for this information!
 
karenpez said:
It is interesting to hear the discussions about a chaperone. I listened to the 2024 CPT symposium regarding the use of this code and a chaperone was never mentioned. The speaker from the CPT symposium stated that anytime a pelvic exam is performed, well or sick visit, you can add this code due to the fact that it is a practice expense only. Just cannot be added with a procedure because a pelvic is included with the procedure. Thank you for this information!
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I agree. I read it is to be used for any screening pelvic examination. No symptoms. Not diagnostic. It is my understanding that you can bill the following when a pap smear is done at a annual physical?? I am referring to commercial insurance only with my example below. Here is a link. https://codingintel.com/billing-pap-smear/
99395 Preventive Exam
Q0091 Pap Smear
99459 Pelvic Examination
I am not sure if a -25 should go on the 99395. I am also not sure if Medicare will pay for the 99459.
P.S. I am incorrect. It can be used for diagnostic.
 
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nneecole said:
I agree. I read it is to be used for any screening pelvic examination. No symptoms. Not diagnostic. It is my understanding that you can bill the following when a pap smear is done at a annual physical??
99395 Preventive Exam
Q0091 Pap Smear
99459 Pelvic Examination
I am not sure if a -25 should go on the 99395. I am also not sure if Medicare will pay for the 99459.
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I disagree that 99459 is only for a SCREENING pelvic exam. That is the guideline for PAP smear, Q0091 but I have not seen that anywhere for 99459.
In my practices, we are using 99459 for a pelvic exam where a chaperone is documented (per ACOG's guidance) and 9920x-9921x, 9924x, or 9938x-9939x are coded. It MAY be appropriate even without a chaperone, but since ACOG valued the code for the work of a chaperone, that is how we are using it. I certainly agree that most coding resources do not specify that a chaperone is required, but my coding team is using the ACOG guidance. We are not using 99459 if there is an additional procedure where a pelvic exam is part of performing that procedure.
In your example of 99395, Q0091, 99459, Medicare will not cover 99395 regardless of modifiers. If the patient is receiving a cervical/breast screening, you may want to consider G0101 if the required elements are performed. G0101 includes a pelvic exam and I would therefore not bill 99459 with G0101.
 
csperoni said:
I disagree that 99459 is only for a SCREENING pelvic exam. That is the guideline for PAP smear, Q0091 but I have not seen that anywhere for 99459.
In my practices, we are using 99459 for a pelvic exam where a chaperone is documented (per ACOG's guidance) and 9920x-9921x, 9924x, or 9938x-9939x are coded. It MAY be appropriate even without a chaperone, but since ACOG valued the code for the work of a chaperone, that is how we are using it. I certainly agree that most coding resources do not specify that a chaperone is required, but my coding team is using the ACOG guidance. We are not using 99459 if there is an additional procedure where a pelvic exam is part of performing that procedure.
In your example of 99395, Q0091, 99459, Medicare will not cover 99395 regardless of modifiers. If the patient is receiving a cervical/breast screening, you may want to consider G0101 if the required elements are performed. G0101 includes a pelvic exam and I would therefore not bill 99459 with G0101.
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And to add to your comment Christine, both G0101 and Q0091 have both a physician and practice expense component. The practice expense component already accounts for the use of a pelvic exam pack and any additional staff time.
 
smihm said:
We are documenting a chaperone is present - I do have some Female providers who do not use a chaperone , was under the impression you wouldn't bill , however I have read that in the CPT changes there is no indication /statement that a chaperone is required in order to bill this code- thoughts? Side note- we have received payment
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Hi, are you documenting the chaperone's name and credentials of just the statement of a chaperone is present? Thank you.
 
sunsetmimi said:
Hi, are you documenting the chaperone's name and credentials of just the statement of a chaperone is present? Thank you.
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As long as the documentation supports that a chaperone was present and a pelvic exam was performed, then we are billing 99459. My providers document the name as a matter of practice (and always have.) Particularly since some resources are not even stating a chaperone is required (but not the guidance I am following), I would call the name/credentials a "best practice" but not "required".
 
Not sure if this helps, but Our EMR has a check box in the physical exam section that is "Chaperone present or not present and our providers are utilizing this to document.
 
If there's a problem during the global ob period that causes them to have to do a pelvic exam at the first ob or a global ante visit and a chaperone is present can you charge for this?
 
nielynco said:
No it may not. It is only for use of a chaperone for a the stated purpose of a female pelvic exam that is done yearly. Or rather let me put it another way. A pelvic exam would be integral to an IUD insertion, endometrial BX, etc as part of the procedure. The staff "helper" is already there to assist so this new code would not apply. If the patient presents with a complaint that requires a full pelvic exam or is being seen for her yearly pelvic exam, you could bill this code if a chaperone was required during the time of this exam. I and would add that this presence would need to be documented in the record.
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what about a vulva biopsy or when done in addition to ultrasounds, specifically more so a transvag ultrasound? :) thank you so much!
 
Korbc said:
what about a vulva biopsy or when done in addition to ultrasounds, specifically more so a transvag ultrasound? :) thank you so much!
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As it is an add-on code, you would need to be billing one of the parent E&M codes. For a biopsy, you would be billing the biopsy code, 99459 would not be applicable.
 
thank you, I figured in that circumstance it wouldn't be applicable but just wanted to double check 😀😀

one of our providers is wondering though if we can use 99459 during the 1st ob visit if chaperone is present because pelvic exams are done at that time. Doesn't anyone know if a chaperone during that time would be considered global or if we can charge the 99459 at these visits as well.....I don't know if you could even use the add on code with the 0500f 1st ob code since that first ob is a no charge visit......
 
Korbc said:
thank you, I figured in that circumstance it wouldn't be applicable but just wanted to double check 😀😀

one of our providers is wondering though if we can use 99459 during the 1st ob visit if chaperone is present because pelvic exams are done at that time. Doesn't anyone know if a chaperone during that time would be considered global or if we can charge the 99459 at these visits as well.....I don't know if you could even use the add on code with the 0500f 1st ob code since that first ob is a no charge visit......
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As 99459 is an add on code, you must be billing one of the base codes to use it. Whatever reference you use for CPT will provide the base codes. They are also listed in at least 2 of the responses in this thread.
 
I'm aware it's an add on code and it would need to be added on to another code. And it'll mostly be used for our annuals and problem visits but was just seeing if you could add it on to a 1st ob code if a chaperone is present because we do pelvic exams at time as well
 
Korbc said:
I'm aware it's an add on code and it would need to be added on to another code. And it'll mostly be used for our annuals and problem visits but was just seeing if you could add it on to a 1st ob code if a chaperone is present because we do pelvic exams at time as well
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No you may not unless you are billing that visit with either a problem E/M service (99202-99215) or a preventive medical visit (9938x-9939x).
 
I may have missed this in the thread as there was a lot of great information, but I have a question on the 99459 usage. This is stated in the CPT presentations as a code to reimburse for the supplies utilized during the pelvic exam and nothing mentioned regarding a chaperone. I do see that it is listed on these threads that a chaperone must be present and documented. SO is it supplies being reimbursed or the chaperone as presenters seem to think it is supplies, not chaperone being present. Thank you in advance. :)
 
altman76 said:
I may have missed this in the thread as there was a lot of great information, but I have a question on the 99459 usage. This is stated in the CPT presentations as a code to reimburse for the supplies utilized during the pelvic exam and nothing mentioned regarding a chaperone. I do see that it is listed on these threads that a chaperone must be present and documented. SO is it supplies being reimbursed or the chaperone as presenters seem to think it is supplies, not chaperone being present. Thank you in advance. :)
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Yes - a lot of information but please do take the time to read through again. ACOG (who created the code and it's value) has stated it is to be used only when there is a documented chaperone. My earlier posts give the links and references.
 
Good morning, I get that the note needs to state chaperone present. My question is, what if the chaperone is a student performing clinicals, for his/her RN class, which would not be considered an office employee. The supplies would still be used for the exam. Can I still bill 99459?
 
lsilbaugh said:
Hello! it states a supply kit of $20. Can someone explain the supply kit and the $20 please? (im newer in coding obgyn)
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Every CPT code is assigned a relative value based on resource costs for a particular service, and then this value is multiplied by a $ conversion factor (Medicare publishes theirs every year) to get the minimum payment that will be reimbursed nationally (and that amount will vary by the location of the practice due to geographic adjustments). Commercial payers do not have to reimburse what Medicare does. The code 99459 was valued based ONLY on direct practice costs and they came up with a value of .68. This multiplied by the current Medicare conversion factor of $32.74 gets you about $22.26 in reimbursement before any geographic adjustments. The assigned value of 0.68 RVUs was based on 4 minutes of clinical staff time associated with chaperoning a pelvic exam and a pelvic exam pack (which contains a speculum) which is required to perform a pelvic exam. These are priced out based on market value in any given year so there is nothing magic or set in stone about saying the pelvic exam pack is worth $20 in any given year. For purposes of setting the resource cost for this pack for 2024, the amount of $20.16 was assigned and the price for the 4 minutes of staff time was costed out at $1.99 and for office supplies (like a light). $0.06 for a total of $22.21.
 
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