Ob-Gyn Coding Alert

Here’s why there’s no guarantee your practice will be paid.

CPT^® 2024 includes a new add-on pelvic exam code, +99459 (Pelvic examination [List separately in addition to code for primary procedure]), discussed in Ob-Gyn Coding Alert volume 26, number 11 article, “Mystery Surrounds How to Use Pelvic Examination CPT^® Code.” However, how you should use this code hasn’t been clear — until now.

The Federal Register states:

Pelvic Exam (CPT^® code +99459)

In September 2022, the CPT^® Editorial Panel created a new CPT^® code for reporting a pelvic exam – CPT^® code +99459. The specialty societies noted that reimbursement for the work would be captured with the problem-oriented E/M code billed for the visit. The CPT^® Editorial Panel agreed, thus the new code is a practice expense only code that captures the direct practice expenses associated with performing a pelvic exam in the non-facility setting. CPT^® code +99459 (Pelvic Exam) captures the 4 minutes of clinical staff time associated with chaperoning a pelvic exam. We proposed the RUC-recommended direct-PE inputs for CPT^® code +99459 without refinement. As a PE-only service, the RUC did not recommend and we did not propose a work RVU for this code.

In other words, this means that if your ob-gyn practice wants to capture the work of a clinical staff member chaperoning a pelvic exam, then you would use +99459. A clinical staff member can include “employees (leased or contracted staff) who work under the supervision of a physician or other QHP to perform, or assist in the performance of, a specified professional service as allowed by law, regulation, and facility policy; but who do not individually report that professional service (payer-specific policies may also affect who may report specific services). Clinical staff includes medical assistants, licensed practical nurses, registered nurses, and the like,” according to your CPT^® manual.

One commenter went on to note that they “believe there was an error with addendum B regarding the PE RVUs for CPT^® code +99459.”

The response was, “We thank the commenter for their support. We do not believe there is an error in Addendum B for CPT^® code +99459. The PE RVUs are listed correctly with 0.68 RVUs for nonfacility and ‘NA’ for facility, as there are no direct-PE inputs for this code in the facility setting. After consideration of the public comments, we are finalizing our direct PE inputs for CPT^® code +99459 as proposed.”

Bottom line: “You can bill this code to insurance, but there is no guarantee it will be paid,” says Melanie Witt, RN, MA, an independent coding consultant in Guadalupita, New Mexico. Also, “practice expense only refers to that portion of the RVU assigned to a code that covers the business costs of a practice to provide the service and includes the supplies, personnel, equipment, etc., that must be used.”