Rely on E/M to Report This Physical Exam Component
Question: A provider in my office examined a patient with male anatomy worried about a lesion on their groin. The provider asked whether this could count as a pelvic exam, reported with 99459, since they performed an exam of the patient’s pelvic area. Would this kind of exam be considered a pelvic exam, per CPT® coding? Texas Subscriber Answer: Even though the provider examined the patient’s pelvic region, remember that evaluation and management (E/M) codes cover physical examinations. For example, according to AAPC’s Codify Lay Term explanation, code +99459 (Pelvic examination (List separately in addition to code for primary procedure)) is intended to be used for patients with female anatomy. Codify says: “At the same encounter as an evaluation and management service, the provider performs a pelvic examination on the patient. This may include examining the external and internal genitalia. The provider may use a tool, such as a speculum, to examine a female patient’s cervix and vagina and collect a Pap smear specimen. The provider also may manually check the size and placement of pelvic organs.” With this in mind, +99459 doesn’t apply to an examination of a patient with male anatomy. The best code for this encounter would be an E/M code from the 99202-99215 (Office or other outpatient visit for the evaluation and management …) series. Make sure you check your documentation to see whether the patient was new or established before selecting a code. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
