Provider Spotlights
In this section, you’ll find a Physician Perspectives archive. These are informational cases we’ve shared across the enterprise, featuring important work your provider peers are doing – to help advance clinical quality and make your day-to-day practice easier.
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CPT code 99459 went into effect on January 1, 2024, and is intended to provide payment for expenses associated with performing pelvic exams in an outpatient practice setting. These expenses may include supplies (speculum, gowns, drapes), equipment (lights) and additional staff time (a chaperone). Gregory DeMeo, DO of First State Women’s Care in Delaware, part of Lifeline Medical Associates, has held numerous leadership positions with ACOG, and is a member of the ACOG Committee on Health Economics and Coding. The committee has worked diligently to create the code and follow it to its approval.
“For years and years, gynecologists have not been reimbursed for the use of a speculum,” says DeMeo.
“The majority of gynecologists, when seeing their patients for annual visits, use preventive medicine codes when billing for the exam. When a preventive medicine code is used, it is the same code that our colleagues in internal medicine use when they see their patients for yearly visits. Those codes do not contain the appropriate equipment package to complete a gynecological exam. Therefore, the speculum and the additional chaperone time is not covered in preventive medicine visits.
“This particular code is something that my group – the Committee on Health Economics and Coding – which I’ve been a member of for decades, has been working on for years,” says DeMeo.
“We finally got it approved last year. There is always a year lag time between approval and when it gets into the federal register. So, it’s been a long hard journey.”
DeMeo says it’s important that clinicians understand how to use the code appropriately. He also notes that many payors are not appropriately paying for this code during preventive medicine visits, but they are paying for it during E/M or problem visits.
The Unified RCM and Compliance teams are also monitoring the payments and denials.
“My philosophy is – the patient doesn’t want any surprises.” says DeMeo. “So, when patients come into the office there is the potential that their insurance company is not going to appropriately pay for this particular code. They may apply it to the deductible or completely transfer the cost of this code to the patient.
“The payors are going to do whatever they can to use that to their advantage. I wanted to be certain that my patients would not be surprised by the potential hidden charge.
“The letter explains the code and that we feel the cost should be reimbursed by their commercial insurance carrier – but it may be passed on to patients.”
ACOG recommends that a chaperone be in the room for all gynecologic exams, regardless of whether the clinician is male or female. In the event a patient declines a chaperone, the charge can still be reported because it’s a combined code that includes the use of a speculum, etc. If a chaperone is not present during the exam it’s best practice to document the reason for refusal in the medical record.
For questions about the CPT code 99459, please contact your Compliance Liaison or the Unified Compliance team.
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