Beginning June 1, 2025, healthcare providers must adapt to Cigna’s 2025 CPT 99459 policy change. This update significantly alters billing practices for pelvic examinations. This demands immediate attention from practice managers, healthcare providers, and RCM teams to maintain compliance and prevent revenue loss.
Understanding the Core Policy Update
Core Change: Cigna will now administratively deny CPT 99459 when submitted with standard Evaluation and Management (E&M) codes (99202–99205, 99212–99215). Consequently, pelvic exams will be considered bundled with these standard E&M services.
Exception: CPT 99459 remains reimbursable when billed alongside preventive E&M codes. However, providers must ensure that documentation clearly supports medical necessity for the separate billing.
Timeline: These changes take effect for all claims with dates of service on or after June 1, 2025.
Why This Policy Change Impacts Your Revenue
This policy change directly affects your practice’s financial health and compliance standing:
- For Claim Accuracy: The update prevents denials and payment delays. Furthermore, it significantly reduces administrative rework for billing staff.
- Regarding Compliance: This aligns with Cigna’s efforts toward billing simplification. Thus, proper adherence minimizes risks associated with payer audits.
- For Revenue Protection: Adhering strictly to the new rule maintains clean claims submission. This ensures proper reimbursement only for preventive services where the code is unbundled.
Four Critical Action Steps for Implementation
Practices must act now to prepare their systems and staff:
- Update Protocols: Review the new requirements immediately. Next, train staff on proper coding and implement claim scrubbing rules to flag incorrect 99459 usage.
- Enhance Documentation: Clarity is crucial. Therefore, link pelvic exams to preventive services when applicable, maintaining detailed records to support standalone billing.
- Adjust Systems: Before the effective date, update EHR templates to reflect the new coding pairs. Also, configure billing software to automatically prevent denied combinations.
- Improve Communication: Educate patients about coverage changes. Finally, verify benefits for preventive versus diagnostic services proactively.
Conclusion
Mastering the Cigna CPT 99459 policy prevents denials and secures your revenue cycle. In summary, adjust your systems and train your staff immediately to ensure full compliance by June 2025.