CPT Code 99459 Billing Guidelines and Reimbursement Updates for 2025

CPT code 99459 was introduced on January 1, 2024 and is an add-on code for pelvic examination performed with an E/M service. This code is for the practice expense of the pelvic exam including clinical staff time and supplies. As an add-on code 99459 must be reported with a primary E/M code and cannot be billed alone.

Important Notes:

• 99459 is an add-on code it cannot be billed alone and must be linked to a primary E/M service.
• It covers staff time, equipment and disposable supplies but not the physician’s work.
• Proper documentation is key to justify its use and ensure compliance.
• The pelvic exam must be medically necessary or part of a preventive visit.
• Coverage varies by payer so check insurance policies beforehand.

99459 CPT Code Description

The purpose of CPT code 99459 is to capture the additional practice expense of a pelvic examination. This includes the cost of supplies such as speculums, gowns and drapes as well as clinical staff time for tasks such as chaperoning the patient during the exam.

This code does not cover the physician’s work during the exam; it only covers the ancillary cost of the procedure.

Importantly, this code does not cover the physician’s work during the exam; instead, it focuses solely on the ancillary costs associated with the procedure.

Applying CPT Code 99459 

CPT code 99459 is an add-on code for outpatient or well-patient office visits so it can be used in many scenarios such as screening and annual wellness visits when the exam is necessary. Since it’s an add-on code it cannot be billed alone and must be reported with a primary service code on the same date of service.

This code can be appended to a defined set of services including new or established patient visits, consultations and wellness exams following CPT coding rules. Medicare and private payers generally follow this list but Medicare may extend it to additional G codes for annual wellness visits or “Welcome to Medicare” exams. As coverage guidelines and coding rules change healthcare providers should stay informed to ensure proper billing and compliance.

Situation:
A 16-year-old girl is seen for irregular periods. After discussing her medical history, the physician determines a pelvic exam is necessary. A female nurse is present as a chaperone.

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

 (For the additional practice expenses of the pelvic exam)Key

Considerations: Consent is important, especially for minors. The provider should explain the purpose of the exam and ensure the patient is comfortable. If the patient declines the exam the provider should document this but 99459 would not be billed.

Appropriate Usage of CPT Code 99459

CPT code 99459 is used when a pelvic examination is performed as part of an E/M service in an office setting (Place of Service 11). CPT code 99459 is used when a pelvic examination is performed as part of an E/M service in an office setting, often handled through specialized physician billing services. The following E/M service codes can be reported with 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 undergoing preventive visits the corresponding HCPCS codes are:

• G0402: Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during 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; includes a personalized prevention plan of service (PPPS), subsequent visit

However, as of now there is no official guidance on whether CPT code 99459 can be reported with these specific HCPCS codes.

CPT 99459 Billing Guidelines for 2025 

To get paid follow these 2025 guidelines:

Pair it with a relevant E/M code:

• Example: 99213–99215 (established patient visits) or 99385–99387 (preventive exams).

Clearly document:

• Why was the pelvic exam performed? Chaperone details (if present). Supplies and staff involvement.

Check payer-specific rules:

• Some insurance plans may bundle this code with an E/M visit. Medicare may have different coverage limitations.

Avoid billing errors:

• 99459 cannot be billed as a standalone service. Make sure it’s medically necessary.

Documentation Requirements

Accurate documentation is key when reporting CPT code 99459. The medical record should clearly state that a pelvic examination was performed as part of the E/M service. If a chaperone was present during the exam, document the chaperone’s name and role and the time spent.

 If a chaperone was offered but declined by the patient, document that as well. Proper documentation ensures compliance with billing rules and supports the medical necessity of the service provided.

Situation: A 45-year-old woman comes in for a well-woman exam. The provider performs a full preventive exam including a pelvic exam. A chaperone is present during the exam to ensure patient comfort.

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 valued at 0.68 relative value units (RVUs) for non-facility settings. This is for approximately 4 minutes of clinical staff time to chaperone the pelvic exam and the cost of supplies such as a speculum. Remember this code does not include physician work RVUs as it’s only for practice expense.

When billing CPT 99459 it should be listed separately on the claim form and in addition to the primary E/M service code. Make sure the primary procedure code reflects the E/M service and CPT 99459 is linked to that primary code.

Be aware that payer policies may vary and some insurers may have specific rules for this add-on code so check with individual payers to ensure compliance and proper reimbursement.

Labor Reimbursement in CPT Code 99459  

CPT 99459 does not have a physician work component so physicians are not reimbursed for their time when performing the exam under this code. Instead, it’s structured to cover overhead expenses like staff time and equipment usage. Billing for equipment that wasn’t used would be hard to justify. There is debate on how staff time is interpreted in this code.  

Some say the requirement for a chaperone which is mandated in some states and medical practices falls under this code. Others say the staff time is for tasks like assisting the patient with undressing, getting on the exam table and positioning which takes at least 4 minutes.

Medicare’s final rules mention “chaperone” but that seems to be one of the factors that contributes to the valuation of staff time rather than requiring a chaperone to be present.

Staff is involved in these exams beyond just being present; it’s helping with patient prep, assisting during the exam and managing post exam tasks like specimen processing and cleanup. But the specifics of how this time is calculated is unclear.

Notably the reimbursement for these 4 minutes of staff time is relatively low compared to the cost of equipment and supplies under this code especially in settings like Hospital Billing Services where compliance and resource tracking is critical.

Discussions on reimbursement and coding often overlook broader healthcare considerations. In states where a chaperone is required for specific medical exams, compliance with legal regulations is key. From a medical and legal perspective documentation of whether a chaperone was offered, accepted or present is becoming more important. But there is no indication that a chaperone will become a required component for billing CPT code 99459. 

Clinical Implications

Medicare’s final rules mention “chaperone” but that seems to be one of the factors that contributes to the valuation of staff time rather than requiring a chaperone to be present.

Staff is involved in these exams beyond just being present; it’s helping with patient prep, assisting during the exam and managing post exam tasks like specimen processing and cleanup. But the specifics of how this time is calculated is unclear.

Notably the reimbursement for these 4 minutes of staff time is relatively low compared to the cost of equipment and supplies under this code especially in settings like Hospital Billing Services where compliance and resource tracking is critical.

Discussions on reimbursement and coding often overlook broader healthcare considerations. In states where a chaperone is required for specific medical exams, compliance with legal regulations is key. From a medical and legal perspective documentation of whether a chaperone was offered, accepted or present is becoming more important. But there is no indication that a chaperone will become a required component for billing CPT code 99459.

Reporting CPT Code 99459 With Modifier 25  

Is CPT code 99459 reportable with an E/M service when modifier 25 is applied?

For example, if a patient has an E/M visit and a cystoscopy on the same day it’s unclear if 99459 can be reported with modifier 25 as long as medical necessity and procedural performance is met. There is no explicit restriction against this combination but medical necessity is the key.

 If a pelvic exam is deferred until the cystoscopy and there is a valid reason to do an E/M service during the procedure it’s generally okay to include it on the claim.

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

Primary E/M Code	Description
99213–99215	Established patient office visits
99385–99387	Preventive medicine services (new patients)
99395–99397	Preventive medicine services (established patients)
G0439	Medicare Annual Wellness Visit (subsequent)

To Wrap Up!

 CPT code 99459 allows providers to account for practice expense for pelvic exams during E/M services. To use it correctly providers must pair it with the right primary E/M codes, document thoroughly and follow payer rules. Stay current on coding changes to ensure accurate billing and reimbursement.

As coding rules change healthcare professionals should stay updated through training, expert advice and professional resources. Using CPT code 99459 correctly supports efficient operations and quality care in women’s health.