See my response to the last question with regard to how the code was valued. Since staff time plus exam light costs are only priced out at $2.05 for the time of the exam, I would say you are probably not going to be denied reimbursement since the cost of the pelvic exam pack represents 99.9% of the resource cost assigned to 99459.
I agree with @nielynco that 99459 seems appropriate in this scenario. When your practice takes on a student/intern, the practice is supervising, directing, and managing their work and responsibilities. So while the student is not being paid, they are performing the work of an employee with oversight by the practice.
thats a good question, i wonder to
This was addressed by posts on Tuesday.
i saw that after, i don't know why it didn't initially show it for me for some reason! thanks so much!
Just because there is a CPT code, does not mean it will get paid. Check payer policy on this issue and as 99459 is a new code this year, payers may be postponing paying until they see how it is being reported - or they may have just decided they don't care about the added expense. They should at least be paying on the annual code unless their policy states they do not cover this code or this patient does not have preventive coverage.
Thanks, yeah so oddly so far it seems to be all of them. I forget if medicaid did or not. I'll check payer policy
looks like medicaid paid for us when i had her at least put it in manually on their website, and i know blue cross processed a couple but i think it went toward the patients deductible....
heyy
Medicare does not pay for preventive services using the CPT E/M codes so these codes would not be billed to Medicare in any case and 99549 could not be an add-on code in that case. They will pay for problem E/M visits and if a pelvic exam is performed during that visit, the 99459 would apply and could be billed (and paid for). Medicare Advantage plans may also pay for it (some of these plans will accept the CPT preventive medicine codes but ask before billing). You would, however, not be able to bill 99459 if you are billing Medicare Q0091 or G0101 as these codes already have staff services and supplies directly pertaining to a pelvic exam built into their valuation via their assigned RVUs.
thanks so much!
Given that using a chaperone is not a diagnosis and there is no diagnostic code that would pertain to this, the code you have used is correct since she would not have needed the chaperone (or the pelvic pack) unless this was performed. Insurers sometimes (no surprise there) like to delay payment or deny services for weird reasons. I will be interested to hear what they do consider an appropriate diagnosis code for 99459 is they do in fact cover it at all.
There may not be a workaround. This was a post from me a few weeks ago on a very similar thread about 99459:
Those are also being appealed.I just got three denials, from claims submitted in January, BC/BS stating, Per payer a problem dx code has to be billed with 99459 to specify why patient required pelvic exam. I'm sure there are many more to come. Ty.There may not be a workaround. This was a post from me a few weeks ago on a very similar thread about 99459:
I did some brief investigation tonight and we are also seeing denials with specific insurances when billing preventive with 99459. Most of the denials are diagnosis related (CO11, MA63, M76). Our organization is appealing these.
I'll note there are several possibilities.
1) Because it is coded appropriately does not mean the carrier will pay for it. Many payors have bundling rules over and above NCCI edits. The carrier may never pay for 99459 with a preventive diagnosis.
2) The carrier did not intend to deny, but did not properly load 99459 into their claims processing system.
3) The carrier wants to review these individually (kind of like when some carriers flag modifier -25) and determine whether or not to pay.
4) Any and all of the above, plus any other reason a payor will decide to not pay a claim.
PS - I have also seen some carriers bundle 99459 with E&M 99202-99215, but not many. In fact, one paid the 99459 and denied 99214.
That is poor documentation by any standard. I would not use 99459 if the ENTIRE documentation of pelvic exam is "no suspicious lesions". We don't even know what organ didn't have the suspicious lesions. If a one time thing and the provider typically documents appropriately, I would just code what is there. If this is an ongoing issue, I would ensure the provider receives education.
I just wanted to share some information I discovered today regarding 99459 and United Healthcare/Oxford. Apparently, when this code was loaded into their systems, it was under the preventive category and not as an add on. As a result, billing 99459 with 99202-99215, 99383-99397 or 9924x would result in a bundling denial. I have been told they have corrected this 04/01/2024. However, for claims prior to 04/01/2024, they will only pay if we (incorrectly) add -25. So:thanks!!
so helpful! just got denials from united saying it's bundled and that must be why!This may be the longest thread I've ever participated in.
99396, 99459 results in a denial of 99396.
99396-25, 99459 results in both lines paid.
I personally did not interpret their prior or current written policies this way, but this is the information we verbally received. I can confirm that our claims resubmitted with -25 were paid.
It is certainly possible other carriers also incorrectly loaded 99459 as something other than an add on. Or that another carrier's policy is to never pay 99459. Just wanted to share my experience. Hope this can help someone else as the struggle is real!!
to my knowledge no
If 99459 is billed with a preventive 9938x-9939x and preventive diagnosis, there should not be a patient responsibility if their plan meets the ACA requirements.
If bundled by carrier, they should be written off. If applied to deductible at time of preventive, I would either submit a form appeal letter, make calls, or submit a reprocessing request on website (if available).
Yes, you can use this if there is a chaperone for a pelvic exam on a patient with a prior hysterectomy.do anyone know if you can charge for this if the cervix or uterus are surgically absent but they do a pelvic exam?
thanks a ton!
Do you happen to have the link to the NCCI guidelines or any other references where it states that modifier 25 shouldn't be appended to cpt 99459? I have coders in my office insisting that it should be appended directly to it and I stand by that it shouldn't. However, I am unable to find any resources that back up my statement.
Thank you! I appreciate your response. What they also point out is that because code 99459 is listed under EM services it should be treated the same as the other EM codes where modifier 25 is allowed. Here is one of their response to me: "99459 is in the E/M section of the CPT manual. The section is titled, "Other Evaluation and Management Services." I've also attached the Optum Encoder modifier crosswalk for 99459. Modifiers 25 and 57 are on the allowed list for this CPT." I totally agree that modifier 25 should not be appended, however they keep recommending to add it to the 99459.
I have to back up because I wrote my response quickly and was thinking of it from the aspect of the pelvic exam, because most add-on codes are procedure codes, not E+M. And optum does sort of treat it that way -
The coders are appending modifier 25 to let payers know that 99459 is a significant, separately identifiable E&M service from the original E&M visit code (99202-99215) and any other services. Looks like some payers are bundling the 99459.
Do you have a reference for Cigna's reversal? I am only able to find references stating Cigna will not pay 99459 with 99202-99215, but may allow with preventive. I cannot seem to locate anything from Cigna about a reversal.