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)
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
NCCI Exclusions
Key Modifiers
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
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
Typical Clinical Indications (ICD-10)
Frequently Asked Questions
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