CJ Wolf
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One of the new CPT® codes in 2024 is the add-on code +99459, Pelvic Examination.
Many coders and auditors have wondered about the appropriate use of this code. In the clinical setting, the pelvic exam is a key part of the female physical examination. This is especially true for many primary care and OB/GYN physicians.
The pelvic exam usually includes an inspection of the external genitalia, use of a speculum to inspect the vagina and cervix, and a bimanual exam (by palpation) to assess the uterus and its attached structures (ovaries and tubes). Sometimes a rectovaginal exam may also be performed but it is frequently omitted.1
The pelvic exam can assist with diagnosing many gynecological problems. It may be performed when there are complaints of abdominal pain, pelvic pain, bleeding, masses, pain with sexual intercourse, vaginal discharge, sexually transmitted infections, infertility, trauma, incontinence, and prolapse, to name some of the instances when it may be helpful.
The add-on code, 99459, should only be considered when pelvic exam is performed along with one of the following codes: 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99242, 99243, 99244, 99245, 99383, 99384, 99385, 99386, 99387, 99393, 99394, 99395, 99396, 99397.
From a Medicare resource-based relative value scale (RBRVS) perspective, the code only has a practice expense associated with it. In other words, there are no physician work relative value units (RVUs) associated with the procedure. The professional work of the clinician is included in the evaluation and management code that is required to be reported to use the add-on code for a pelvic exam. Reimbursement for the code represents the medical practice’s expense of clinical staff time and supplies that are utilized when a pelvic exam is performed. In most cases, a staff member will join the clinician in the examination room while the pelvic exam is performed.
According to the Medicare Physician Fee Schedule Final Rule, “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.”2
The national, non-facility payment rate (i.e., not adjusted for locality) is $22.64.
The Society of Gynecologic Oncology (https://www.sgo.org/resources/coding-corner-making-sense-of-the-new-add-on-codes-99459-update-with-code-number-leslie-bradford-md/) and the American College of Obstetricians and Gynecologists (https://www.acog.org/news/news-articles/2023/10/acog-win-cms-increases-payment-for-pelvic-exams) have both published comments about the new add on code.
Additionally, some Medicare Administrative Contractors (MACs) have published guidance about this new code. For example, NGS has issued a post on their website (https://www.ngsmedicare.com/web/ngs/news-article-details?lob=96664&state=97178&rgion=93623&selectedArticleId=11186526).
Apart from Medicare, it is also important to check with other payors regarding their policy. One commercial payor is covering the service in some cases, but has written that, “CPT® code 99459 may not be payable in all circumstances due to other policies or guidelines.” (https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/preventive-care-services.pdf)
Resources
[1] Bialy A, Kondagari L, Wray AA. Gynecologic Pelvic Examination. [Updated 2024 Feb 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534223/
[2] Federal Register, Vol. 88, No. 220, page 78912. Thursday, November 16, 2023, Rules and Regulations.
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