New CPT Add-on 99459

[SantaRosa27]

CPT® 99459 – pelvic exam, is a direct practice expense only code that may be billed with E/M services when practitioners are providing a pelvic exam to patients during an E/M. It has .68 facility RVUs. Can it be billed if G0101 is billed, Cervical or vaginal cancer screening; pelvic and clinical breast examination? G0101 has a facility RVU of .66 so I think it would be double dipping.

 

[jabowen]

CPT code book has the codes you can report this with and G0101 is not on the list.

 

[CBLENNIE]

Have you reviewed the discussion of this code in the post titled add on code 99459? There is an extensive discussion of this code and why it was developed and what it should be billed with, including the citation from the federal register regarding rationale regarding 99459 and its use.

I agree that G0101 is not on the list of primary codes that add-on code 99459 can be billed with, I'd also like to point out that CPT code 99459 was created to capture the practice expense of having a chaperone present during a pelvic exam. So, if you do have claims with a valid primary procedure code that you want to bill 99459 with you can only do so if there was a chaperone present for the pelvic exam.

Please review the linked post add on code 99459 which provides the regulatory guidance related to 99459 along with the CPT Editorial Panel's rationale for creation of this new code.

 

[prusso]

Per the live webinar attended from AAPC yesterday, a chaperone is not required. This is just an example of what type of expense this could encompass along with supplies used and time spent.

 

[csperoni]

Per the live webinar attended from AAPC yesterday, a chaperone is not required. This is just an example of what type of expense this could encompass along with supplies used and time spent.

This is an active discussion on the other thread already mentioned by @CBLENNIE. Here is a portion of one of my posts:
In my practices, we are using 99459 for a pelvic exam where a chaperone is documented (per ACOG's guidance) and 9920x-9921x, 9924x, or 9938x-9939x are coded. It MAY be appropriate even without a chaperone, but since ACOG valued the code for the work of a chaperone, that is how we are using it. I certainly agree that most coding resources do not specify that a chaperone is required, but my coding team is using the ACOG guidance. We are not using 99459 if there is an additional procedure where a pelvic exam is part of performing that procedure.

 

[RSDixon]

Anyone having trouble with ICD-10 payer denials and have any suggestions for OB/GYN well women visits diagnosis when billing out with Z01.419 or Z01.411 and Z12.4. What code is appropriate in these scenarios for CPT 99459. Is there any references you could point me to. Thank you.

 

[SoberAsABird]

Anyone having trouble with ICD-10 payer denials and have any suggestions for OB/GYN well women visits diagnosis when billing out with Z01.419 or Z01.411 and Z12.4. What code is appropriate in these scenarios for CPT 99459. Is there any references you could point me to. Thank you.

We're getting denials with the 99396 and 99459 both using the z01.419 ICD code without a modifier. Currently appealed and under a manual review so we'll see what happens in 30 days. This is with two insurance companies so far.

 

[csperoni]

Anyone having trouble with ICD-10 payer denials and have any suggestions for OB/GYN well women visits diagnosis when billing out with Z01.419 or Z01.411 and Z12.4. What code is appropriate in these scenarios for CPT 99459. Is there any references you could point me to. Thank you.

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. Those are also being appealed.