CPT code 99459: Add on Code for Pelvic Examination

No, CPT 99459 can only be billed with a specific list of eligible primary E/M codes, primarily office or other outpatient new and established patient visits, office/outpatient consultations, and new and established patient preventive medicine services.

Generally, CPT 99459 can be reported only once per patient per day, even if multiple pelvic examinations are performed during the same encounter.

While the CPT description doesn't explicitly mandate specific documentation beyond the performance of the pelvic exam, it's crucial to document the indication for the pelvic exam and the key components of the examination performed (e.g., external inspection, speculum exam, bimanual palpation).