CPT Code 99499: Unlisted Evaluation and Management Service

What is CPT code 99499?

CPT code 99499 is defined as "Unlisted evaluation and management service" in the Current Procedural Terminology (CPT) codebook published by the American Medical Association. This code functions as a placeholder when a provider performs an evaluation and management (E/M) service that doesn't have a specific CPT code assigned to it.

The fundamental purpose of CPT 99499 is to provide a mechanism for reporting services that fall outside the standard E/M code set. It serves as a catch-all option when the service provided doesn't align with existing CPT codes, either because it's innovative, uncommon, or combines elements of multiple services in a way that makes using established codes inappropriate.

While CPT 99499 should never be used as a default for difficult coding situations that would fit a specific code, several legitimate scenarios exist where this code may be appropriate:

• Novel or emerging services that haven't yet received specific CPT codes
• Unusual combinations of services that don't fit established codes
• Services provided under unusual circumstances that significantly alter the nature of the encounter
• Services that exceed the highest level of established E/M codes in terms of complexity or time

CPT code 99499 documentation requirements

When using CPT code 99499, documentation should be exceptionally thorough and detailed, whether in an outpatient or inpatient setting. The medical record should include a comprehensive description of the service provided, clearly explaining what was done, why it was necessary, and how it differs from standard coded procedures.

The clinical rationale must be explicitly stated, connecting the service to the patient's condition and demonstrating why it was medically necessary for their specific presentation or circumstances.

It's also crucial to document the time spent providing the service, detailing both face-to-face and non-face-to-face time when applicable, as time often becomes an important factor in determining appropriate reimbursement for unlisted services.

CPT code 99499 billing guidelines

Billing unlisted services presents unique challenges. Following proper guidelines is essential for maximizing the likelihood of reimbursement and avoiding costly delays or denials.

The submission process for claims containing CPT code 99499 requires special attention and additional documentation. Most insurance payers, including Medicare, require that claims with unlisted codes be submitted with supporting documentation attached rather than electronically. This typically includes a cover letter that clearly identifies the unlisted service, explains why it was necessary, and justifies why an unlisted code was used instead of an established CPT code.

Establishing an appropriate fee for services reported with CPT code 99499 requires a methodical approach. The "relative value" method is widely recommended. The provider compares the unlisted service to similar established services with known values in this method. This comparison should consider time, skill level, risk, and resources required.

When determining the fee, it's important to document how the charge was calculated, providing a clear rationale that connects the fee to established services. Some private payers may request that providers suggest a specific payment amount based on their analysis of comparable services.

Other relevant codes

When considering alternatives to CPT code 99499, several other codes might be more appropriate depending on the specific scenario:

• 99242-99245: Office or other outpatient consultations for new or established patients (if still recognized by the payer)
• 99366-99368: Medical team conferences