CPT code and Description
Reporting CPT code 99499 (Unlisted evaluation and management service) should be limited to cases where there is no other specific E/M code payable by Medicare that describes that service Reporting CPT code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. Contractors shall expect reporting under these circumstances to be unusual.
CPT 99499 usage example
the inpatient hospital setting and the nursing facility setting, physicians (and qualified nonphysician practitioners where permitted) may bill the most appropriate initial hospital care code (99221-99223), subsequent hospital care code (99231 and 99232), initial nursing facility care code (99304-99306), or subsequent nursing facility care code (99307-99310) that reflects the services the physician or practitioner furnished. Subsequent hospital care codes could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252. Contractors shall not find fault in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay. Unlisted evaluation and management service (code 99499) shall only be reported for consultation services when an E/M service that could be described by codes 99251 or 99252 is furnished, and there is no other specific E/M code payable by Medicare that describes that service. Reporting code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. CMS expects reporting under these circumstances to be unusual.
Top 10 insurance allowed amounts
This is approximate amount and not the exact amount. Pls double confirm by reaching the insurance company directly.
| Insurance Company | Allowed Amount |
|---|---|
| Medicare | $350.00 |
| Medicaid | $250.00 |
| Blue Cross Blue Shield | $300.00 |
| UnitedHealthcare | $275.00 |
| Aetna | $325.00 |
| Humana | $295.00 |
| Cigna | $310.00 |
| Oscar | $280.00 |
| WellCare | $260.00 |
Medicare Insurance Coverage Guidelines:
Medicare does not have specific coverage guidelines for CPT code 99499. This code is used for “Unlisted Evaluation and Management (E/M) Service.” It is typically used when there is no other specific E/M code available to describe the service provided.
Coding Guidelines and Examples:
CPT code 99499 should be used sparingly and only when no other appropriate E/M code is available.
It is important to include detailed documentation describing the service provided to support the use of this code.
Examples of scenarios where CPT code 99499 may be used include unique or unusual patient cases that do not fit any other E/M code description.
Modifier Usage:
Modifiers may be used with CPT code 99499 to provide additional information or clarify the circumstances of the service provided. Commonly used modifiers with this code include:
Modifier 25: This modifier indicates that a separately identifiable evaluation and management service was performed on the same day as another procedure or service.
Modifier 59: This modifier is used to indicate a distinct procedural service.
Allowed ICDs (Diagnosis Codes):
CPT code 99499 does not have specific allowed ICD codes. The diagnosis code used with this unlisted E/M code should reflect the reason for the evaluation and management service provided.
Bundled Codes with Other CPTs:
CPT code 99499 represents an unlisted E/M service and is typically used when there is no other specific E/M code available. It is not typically bundled with other specific E/M codes. However, it is important to review Medicare’s National Correct Coding Initiative (NCCI) edits for any potential bundling issues specific to the service provided.
Different Denial Reasons:
Denial reasons for CPT code 99499 could vary depending on the circumstances and documentation submitted. Some common denial reasons include:
Lack of medical necessity: Insufficient documentation or justification for using an unlisted E/M code.
Unspecified or incomplete information: Inadequate details provided in the medical record to support the service rendered.
Incorrect coding or billing: Coding errors, such as incorrect modifier usage or incomplete submission of required information.
Facts and Common Questions:
Q: Can I use CPT code 99499 for routine office visits?
A: No, CPT code 99499 is not intended for routine office visits. It should only be used when no other specific E/M code accurately describes the service provided.
Q: How can I ensure proper reimbursement for CPT code 99499?
A: It is crucial to provide thorough and detailed documentation supporting the medical necessity of using an unlisted E/M code. Clear and comprehensive documentation is essential for accurate reimbursement.
Q: Is prior authorization required for CPT code 99499?
A: Prior authorization requirements can vary depending on the Medicare contractor or specific program. It is recommended to check with the Medicare Administrative Contractor (MAC) or review the local coverage determination (LCD) for any prior authorization requirements.
Q: Can I use CPT code 99499 if there is a specific E/M code that partially describes the service?
A: No, if a specific E/M code partially describes the service provided, it is important to use the most accurate and specific E/M code available rather than resorting to the unlisted code.
Q: What should I do if my claim with CPT code 99499 is denied?
A: If your claim is denied, review the denial reason provided by Medicare and assess if any errors or missing information contributed to
