Jan 2025: New Chaperone CPT Code

For years, practices performing speculum exams have faced a significant oversight in medical billing: the lack of reimbursement for essential resources such as speculums and clinical staff acting as chaperones. Chaperones during gynecological exam provide value as they can enhance patient comfort, privacy, and safety by providing a witness during a sensitive procedure, potentially reducing anxiety and protecting both the patient and clinician from misunderstandings or allegations of improper behavior. Recognizing this gap, the American College of Obstetricians and Gynecologists (ACOG), along with other professional groups, have successfully advocated for a change that promises to enhance the financial sustainability of such essential women's health services. There is now a CPT code for use of a chaperone during a gynecologic pelvic exam.

How the New CPT Code Works

The newly introduced CPT code 99459 is designated as a practice expense-only code. This means it compensates for the operational costs—such as supplies and clinical staff time—without covering any physician work. The code values the practice expense relative value unit (RVU) at 0.68, which equates to about four minutes of clinical staff time necessary for chaperoning a pelvic exam.

Physicians should note that the work performed during the speculum exam itself should continue to be reported with the problem-oriented evaluation and management (E/M) code billed for the visit. E/M codes differ based on the complexity of the patient encounter, or the time spent, ultimately impacting the reimbursement level for a medical visit. The complexity of medical decision-making could increase if a pelvic exam is required to properly diagnose and formulate a treatment plan, which justifies the use of the E/M code.

Implications for Non-Facility Settings

It's important to highlight that this new CPT code is applicable only in non-facility settings, such as private practices or clinics separate from a hospital. Hospital-based practices typically incorporate the cost of supplies and chaperone services into their facility fees, which cover a broader range of patient care costs. This distinction ensures that the new code specifically addresses the financial challenges faced by non-facility practices without duplicating coverage provided in hospital settings.

What This Means for Fertility Practices

In evaluating the new CPT code, it unfortunately can only be used when tied to an E/M charge. This means that the chaperone CPT code cannot be used for use of a chaperone for procedures such as an intrauterine insemination (IUI) or saline sonohysterography (SIS) procedures. It also cannot be used for embryo transfers or use of a chaperone for a transvaginal pelvic ultrasound. If you perform a pelvic exam at a new patient visit or perform a mock embryo transfer tied to an E/M charge, then this code could be used.

The Way Forward

Practices should update their billing systems and train their administrative and nursing staff to utilize this new code effectively. This may include training staff to document the chaperone. Fertility centers would be best served having a work flow to ensure documentation of the chaperone in the medical record when adding the CPT code 99459 to a clinic visit. For instance, many clinics will have a template or smartphrase made that includes verbiage documenting that a chaperone was present. Other centers may even set up their electronic medical records in such a fashion that a note cannot be signed unless a chaperone is documented. By doing so, they can ensure that they are reimbursed for the full scope of their services.

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