OBGYN Coding Alert - 5 Must-Know FAQs for +99459 Expense Code
These FAQs clarify its use and help coders accurately report this new expense-only code.
FAQs for +99459 Expense Code
In 2024, CPT code +99459 was introduced as an add-on for pelvic examinations to be used alongside new and established patient visit codes (99202–99205, 99212–99215), consultation codes (99242–99245), and preventive medicine codes (99383–99397). These FAQs clarify its use and help coders accurately report this new expense-only code.
Why Did CMS Implement This Code?
According to the American College of Obstetricians and Gynecologists (ACOG), the Centers for Medicare & Medicaid Services (CMS) established this code to help cover the expenses related to pelvic examination packs, such as speculums, and the costs of having an in-room chaperone for patients receiving female pelvic examinations during an outpatient evaluation and management visit.
These expenses can be substantial. For instance, in 2015, there were about 52 million pelvic exams conducted in the United States. This code aims to alleviate some of the financial burdens that ob-gyns and other physicians incur. The relative value assigned to this code is based on the assumption that an in-room chaperone and a pelvic exam pack are used during the examination.
What Codes Can I Report +99459 With?
If your physician documents pelvic exams appropriately, you can report +99459 alongside one of the following evaluation and management (E/M) codes:
- Office or other outpatient visit for a new patient: 99202-99205
- Office or other outpatient visit for an established patient: 99212-99215
- Consultation codes: 99242-99245
- Preventive visit codes: 99383-99387, 99393-99397
Note: For Medicare patients receiving a preventive visit, use one of the following HCPCS codes:
- G0402: Initial preventive physical examination; face-to-face visit, services limited to new beneficiaries within the first 12 months of Medicare enrollment.
- G0438: Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit.
- G0439: Annual wellness visit; subsequent visit.
- G0468: Federally qualified health center (FQHC) visit, including IPPE or AWV; a visit that includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV), including a typical bundle of Medicare-covered services.
There is currently no guidance on whether +99459 can be reported with these HCPCS codes. However, for Medicare-eligible patients undergoing a screening pelvic exam, the codes G0101 (for the pelvic exam) and Q0091 (for the collection work) can be reported with one of these preventive services. Both codes address the practice expenses related to the exam, suggesting that +99459 may not be applicable in addition.
What Codes Should I Not Report +99459 With?
You should avoid reporting +99459 with the following codes:
- Postoperative visits (99024) since these are typically included in the global surgical package and cover follow-up evaluations related to the original procedure.
- Medicare codes G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and Q0091 (Screening Papanicolaou smear; obtaining, preparing, and conveying the cervical or vaginal smear to the laboratory) as these services are separately bundled and not to be reported alongside +99459.
How Often Can I Report This Code?
You can report pelvic exam code +99459 only once per patient per day, regardless of how many times a pelvic exam is performed or how many related codes are billed. This restriction applies when +99459 is used with one of the previously listed codes.
What Documentation Does the Ob-Gyn Need to Provide?
ACOG guidelines emphasize that documentation must justify the need for a pelvic examination and confirm the presence of a chaperone. Adding a “chaperone present: yes/no” option to the EHR (electronic health record) template for pelvic exams or including a statement like “chaperone present during pelvic exam,” can be effective.
Things To Remember:
ACOG guidance indicates that pelvic examination should be performed when indicated by medical history or symptoms or as a result of shared decision-making between the patient and their obstetrician-gynecologist or other gynecologic care professional. A pelvic exam may or may not be performed at the annual preventive visit, and one would not be required before providing contraception. However, a pelvic exam would most likely be performed if the provider is screening for sexually transmitted infections, and a pelvic exam would always be performed before any gynecologic procedures, such as an intrauterine device (IUD) insertion. This does not mean that the add-on code can be reported when an exam is performed under these circumstances." This is because a pelvic pack and pre-procedure evaluation time have already been accounted for in the practice expense relative value assigned to the IUD insertion code (58300).
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BillingFreedom excels in OBGYN medical billing by offering specialized expertise tailored to the complexities of obstetrics and gynecology. We ensure accurate coding and billing, including the latest pelvic exam code +99459, to capture all eligible expenses for pelvic examinations. Our team is proficient in navigating CMS guidelines and preventive visit codes, maximizing reimbursements while minimizing errors. With a focus on detailed documentation and up-to-date practices, we handle everything from routine visits to complex procedures, ensuring compliance and optimizing revenue.
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