Coding Corner: Practice Expense Code for Pelvic Examinations | David Holtz, MD

David Holtz, MD

It has long been recognized by obstetricians and gynecologists that the complete female physical examination requires more than a general medical exam absent a pelvic exam. All patients require a gown, extra materials such as gel and a speculum, and the participation of a chaperone. The American College of Obstetricians and Gynecologists (ACOG), assisted by SGO, has advocated for many years to obtain additional reimbursement in recognition of the extra practice expense (PE) inputs necessary in the provision of the female pelvic examination.

At the September 2022 American Medical Association (AMA) CPT® Editorial Panel Meeting, the Panel approved a new code to capture the PE of providing a clinical staff chaperone during a pelvic examination. The new CPT code 9X036 is a PE-only code, and therefore has no physician work (i.e., work relative value unit (RVU)) associated with the service. As such, the code is valued at 0.68 PE RVUs which captures four minutes of clinical staff time when chaperoning a pelvic exam. The code may be reported with evaluation and management (E/M) services in the non-facility/office setting. Note that the medical documentation must support that a pelvic exam was performed. This code should not simply be added to every female medical exam without the proper documentation. The new code was included in the Centers for Medicare and Medicaid Services (CMS) Medicare Physician Fee Schedule proposed rule, and it is expected that the code will be approved by CMS in the final rule, ready for implementation and use starting January 1, 2024.

David Holtz, MD, is a gynecologic oncologist at Main Line Health in Wynnewood, PA, and Chair of the SGO Coding and Reimbursement Subcommittee.