Wiki Chaperone code 99459 diagnosis codes

[kellyjseidl@gmail.com]

I work in an OBGYN office and have been billing the new CPT 99459 (chaperone code). We have billed it with prevent visits, as well as problem visits, with mixed results from insurance companies.
Anthem has rejected for invalid dx code with the prevent code. The dx used was Z01.419. From what I understand of this new code, this is the prime example of what the code is to be used for.
UHC has rejected the use of the code with prevent visits. And they have paid the code with a problem visit.
Does anyone have information on payable diagnosis codes with these insurances? Are you billing with any modifiers? This is an add on code, so we have not, as of yet.

Thanks in advance for any advice
Kelly

 

[TThivierge]

Hi Kelly
Yes it can be used but follow these guidelines for +99459........
1. Document the chaperone in the treatment room person there such as RN, CMA,QMHP,
2. Can be used with Eval Mgnt cpt codes, consult and preventive visits as add on, use in office & clinic settings not hospital
3.Do not bill with follow up CPT 99024 or G0101 Medicare code
4. I would not use Z01.4 as primary with this CPT of 99459. I d use dx Z01.419 with preventive codes first such as for annual pap CPT 99383-99397. Link symptoms or dx for problem why patient getting a pelvic exam with 99459. Some examples Pelvic Pain,R10.2 N89.8 pessary ulcer N81,8 N80 N85.5 N84.8 B37.41 D28.0 N90.5, N92.6 as possible dx once documented due to supported physical illness.
I hope helped you just a little bit more in this coding dilemma.
Lady T

 

[csperoni]

I agree with 1-3 above by @TThivierge but not #4.
I'll note as with ANY new CPT, there will be some carriers that have not properly updated their systems by January 1, so you may experience more denials in the beginning of the year. This code is for the additional staff time and supplies for a pelvic exam. To my knowledge, there are no specific required ICD10 codes as I would imagine there are literally thousands of appropriate diagnoses. I would shy away from obviously inappropriate diagnoses that could require a pelvic exam. For example, if you are treating a breast lump and a complaint of possible yeast infection, I wouldn't put the breast diagnosis on 99459.
While the CPT guidelines are that 99459 is appropriate to code along with problem oriented E&M 99202-99215, preventive 9938X-9939X, and consult 99242-99245, just because it is appropriately coded does not mean all carriers will pay for it.
You are correct in that 99459 should not require any modifier as it is an add on code.

It sounds like you are coding it correctly, but some payors have either not properly updated their systems or have created a policy to not pay under certain circumstances.
For example, UHC states this:
Pelvic Examination add-on code 99459: Preventive care services benefits may apply to 99459 when the related evaluation and management (office visit)code is applied to the preventive cares ervices benefit. CPT code 99459 may not be payable in all circumstances due to other policies or guidelines.
I interpret that as "hey, MAYBE we'll pay if we feel like it."

Currently, I am rarely involved in denials like this, but I have not incidentally noticed any yet.