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E/MAdd-on2026 Compliant

CPT 99459

2026 Billing Guide

Pelvic Exam Add-on

Reimbursement

$23.05

Threshold

N/A

2026 Status

Active

What is CPT Code 99459?

CPT 99459 is defined as: An evaluation and management (E/M) add-on code used to report the additional clinical staff time and supplies required to perform a pelvic examination. This code is listed separately in addition to the code for the primary E/M service (e.g., an office visit). It captures the Practice Expense (PE) resources involved in setting up the exam room and assisting during the procedure.

This code is primarily used for E/M services. It falls under the category of Evaluation & Management and is valid for the 2026 calendar year according to the CMS Physician Fee Schedule.

2026 RVU Components

Relative Value Units (Non-Facility)

Standard Formula Applied

Work RVU

0

Physician Effort

PE (Non-Fac)

0.68

Practice Expense

Malpractice

0.01

Risk Factor

Total RVU

0.69

Note: [(Work RVU * Work GPCI) + (PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor

2026 CMS Policy Intelligence

efficiency shield

Strategically exempt from the -2.5% efficiency adjustment. Because it is an add-on to protected E/M services and carries no Work RVU, it is unaffected by physician-work devaluations.

resource valuation

CMS maintains 99459 in 2026 to ensure that primary care and OB/GYN practices are not financially penalized for the high supply/labor costs associated with pelvic exams.

conversion factor

Utilizes the 2026 Non-QP rate of $33.40.

Administrative Framework

Place of Service

11 (Office)

NCCI Exclusions

Do not bill with:G0101Q0091

Key Modifiers

N/AAdd-on code; typically does not take modifiers like 25 unless part of a complex surgical session.

Required Primary Codes

Must be billed alongside a primary service.

Operational Requirements

performance requirement

Must be billed in conjunction with an office or outpatient E/M code where a clinical pelvic exam was actually performed.

documentation content

The medical record must contain the findings of the pelvic examination to justify the use of 99459.

pe only nature

CPT 99459 has a Work RVU of 0.0; its entire value is based on Practice Expense (PE) to cover the cost of the speculum, drapes, and chaperone/staff time.

site restriction

Typically only reimbursed in the Non-Facility (Office) setting where the practice incurs the supply costs.

Compliance Checklist

Detailed time tracking (cumulative for the month).
Specific clinical decision-making documentation.
Electronic care plan availability and access log.

Audit Defense

No specific audit defense elements defined.

2026 Update

Exempt from the mandatory -2.5% efficiency cut. Must be billed with a primary E/M code.

Common Clinical Scenarios

No clinical examples provided.

Target Specialties & Utilization

OB/GYNFamily MedicineInternal Medicine

Typical Clinical Indications (ICD-10)

Z01.419 (Encounter for gynecological examination without abnormal findings)N93.9 (Abnormal uterine and vaginal bleeding, unspecified)R10.2 (Pelvic and perineal pain)

Frequently Asked Questions

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