CPT Code 99459: Billing Guidelines and Reimbursement Updates for 2025

CPT code 99459, introduced on January 1, 2024, is an add-on code designated for pelvic examinations performed in conjunction with an Evaluation and Management (E/M) service. This code is specifically designed to account for the practice expenses associated with conducting a pelvic exam, including clinical staff time and necessary supplies. As an add-on code, 99459 must be reported alongside a primary E/M service code and cannot be billed independently.

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 checking insurance policies beforehand is critical.

99459 CPT Code Description

The primary purpose of CPT code 99459 is to capture the additional practice expenses incurred during a pelvic examination. These expenses include the cost of supplies, such as speculums, gowns, and drapes, as well as the clinical staff time required for tasks like chaperoning the patient during the examination. 

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 serves as an add-on code for outpatient or well-patient office visits, making it applicable in various scenarios, such as screening and annual wellness visits, when these examinations are necessary. Since it is classified as an add-on code, it cannot be billed independently and must be reported alongside specific primary service codes 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 standard CPT coding practices. Medicare and private insurers generally adhere to this list, though Medicare may extend its use to additional G codes for annual wellness visits or “Welcome to Medicare” exams. As coverage guidelines and coding requirements may evolve, healthcare providers should stay informed about any updates to ensure proper billing and compliance.

Situation:A 16-year-old girl is seen for concerns about 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 applicable 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 applicable 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 are appropriate to report in conjunction 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 ensure reimbursement, follow these updated 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.
• Ensure it aligns with medical necessity requirements.

1. Documentation Requirements

Accurate and thorough documentation is crucial when reporting CPT code 99459. The medical record should clearly indicate that a pelvic examination was performed as part of the E/M service. Additionally, if a chaperone was present during the examination, this should be documented, including the chaperone’s role and the time spent. 

In cases where a chaperone was offered but declined by the patient, this refusal should also be recorded. Proper documentation ensures compliance with billing guidelines and supports the medical necessity of the services provided.

Situation:A 45-year-old woman visits a gynecologist for an annual well-woman exam. The provider performs a full preventive examination, including a pelvic exam. A chaperone is present during the exam to ensure patient comfort. Billing:Primary E/M code: 99386 (Preventive visit for a new patient, aged 40–64)Add-on code: 99459 (To capture the cost of supplies and staff time during the pelvic exam) Documentation Requirements:The medical record should indicate that a pelvic exam was performed.The name and role of the chaperone should be documented.If the patient declined a chaperone, that should also be noted.

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 valuation accounts for approximately four minutes of clinical staff time associated with chaperoning a pelvic exam and the cost of necessary supplies, such as a speculum. It’s important to understand that this code does not include physician work RVUs, as it is intended solely to cover practice expenses. 

When billing for CPT code 99459, it should be listed separately on the claim form, in addition to the primary E/M service code. Ensure that the primary procedure code reflects the E/M service provided and that CPT 99459 is appropriately linked to this primary code. 

Be aware that payer policies may vary, and some insurers may have specific guidelines regarding the reimbursement of this add-on code. Therefore, it’s advisable to verify coverage and billing requirements with individual payers to ensure compliance and appropriate reimbursement.

Labor Reimbursement in CPT Code 99459  

CPT code 99459 does not include a physician work component, meaning that physicians are not directly reimbursed for their labor when performing the examination under this code. Instead, the reimbursement is structured to cover overhead expenses, such as staff time and equipment usage. Billing for equipment that was not utilized would be difficult to justify.  

There is some debate regarding how staff time within this code is interpreted. Some believe that the requirement for a chaperone, which is mandated in certain states and medical practices, may fall under this allocation. Others argue that the staff time accounts for tasks like assisting the patient with undressing, getting onto the examination table, and positioning activities that typically take at least four minutes.  

While Medicare’s final rules mention “chaperone,” this reference appears to illustrate one of the factors contributing to the valuation of staff time rather than mandating a chaperone’s presence. The involvement of staff in these examinations extends beyond just being present; it includes helping with patient preparation, assisting during the exam, and managing post-examination tasks such as specimen processing and cleanup. However, the specifics of how this time is calculated remain unclear. Notably, the reimbursement assigned for these four minutes of staff time is relatively low compared to the costs associated with equipment and supplies under this code, especially in settings such as Hospital Billing Services where compliance and resource tracking are critical.

Discussions on reimbursement and coding often omit broader healthcare considerations. In states where a chaperone is required for specific medical examinations, compliance with legal regulations is essential. From both medical and legal perspectives, documentation of whether a chaperone was offered, accepted, or present is increasingly important. However, there is no indication that the inclusion of a chaperone will become a required component for billing CPT code 99459.  

Clinical Implications

The introduction of CPT code 99459 underscores the importance of recognizing the additional resources required to perform a comprehensive pelvic examination. Accounting for practice expenses ensures healthcare providers can deliver thorough and sensitive care to patients. This code acknowledges the necessity of clinical staff involvement, the use of specialized equipment, and the time dedicated to ensuring patient comfort and safety during the examination.

Incorporating CPT code 99459 into billing practices not only facilitates appropriate reimbursement but also highlights the commitment to providing comprehensive women’s health services. Providers should ensure that their billing and coding staff are well-informed about the proper use of this code to optimize practice operations and maintain compliance with current billing standards.

Reporting CPT Code 99459 With Modifier 25  

A common inquiry is whether CPT code 99459 can be reported alongside an evaluation and management (E/M) service when modifier 25 is applied. For example, if a patient has both an E/M visit and a cystoscopy on the same day, it is unclear whether code 99459 can be reported concurrently with modifier 25, provided that medical necessity and procedural performance are met.  

Currently, there are no explicit restrictions against this combination. However, medical necessity remains the key factor. If a pelvic examination is deferred to coincide with a cystoscopy, and there is a valid reason for conducting an E/M service during the procedure, it is generally acceptable to include it in 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 helps healthcare providers account for practice expenses related to 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-specific guidelines. Staying updated on coding changes ensures accurate billing and proper reimbursement.  

As billing rules change, healthcare professionals should continuously update their knowledge through training, expert consultations, and professional resources. Proper use of CPT code 99459 supports efficient operations and reflects a commitment to quality care in women’s health.