Overview

CPT 99459 is an add-on code used to report a pelvic exam performed alongside an Evaluation & Management (E/M) visit. It captures practice expenses such as staff time (typically around 4 minutes) and supplies like speculums, not the clinician's work. This code must be billed in conjunction with a valid E/M code such as 99202–99215, preventive care codes, or consultation codes. It cannot be used alone.

Purpose

CPT 99459 acknowledges the additional resources required for pelvic exams, especially in women's health settings. It ensures fair reimbursement for supplies and clinical staff, enhancing revenue integrity without overcounting provider effort.

Clinical Scenarios for CPT 99459

Annual well-woman exams that include a pelvic exam alongside preventive E/M codes
Problem-focused visits for symptoms such as pelvic pain or abnormal bleeding, where a pelvic exam is essential
Consultation visits, such as new OB/GYN evaluations, where a pelvic examination is performed

Documentation Requirements

Indicate the medical necessity of the pelvic exam
Detail the exam components, such as the use of a speculum, specimen collection, and external or internal assessment.
Note the presence of a chaperone or whether one was offered and declined for documentation completeness.

Billing and Reimbursement Tips

Always bill 99459 with an eligible E/M code and never alone
Check payer policies because while most reimburse, some, like Cigna, now deny 99459 with standard office E/M codes unless used with preventive E/M codes
Verify per-payer reimbursement guidelines since many are payer-specific and may require prior authorization or internal policy review
Bill 99459 only once per patient per day, even if multiple exams occur during that encounter

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98–99% clean claim rate with airtight documentation alignment and modifier accuracy

Why It Works

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You focus on patient care. We ensure that your pelvic exam services are fully and promptly paid for.

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