2025 CPT code 99455
(Active) Effective Date: N/A Revision Date: N/A Evaluation and Management - Work Related or Medical Disability Evaluation Services Evaluation and Management > Special Evaluation and Management Services Feed
This CPT code reports a comprehensive medical evaluation for work-related or medical disability, including history, examination, diagnosis, assessment of capabilities, impairment calculation, treatment planning, and report generation.
Modifiers may be applicable depending on the circumstances of the evaluation. For instance, modifier 25 may be used if a significant and separately identifiable E/M service is provided on the same day. Consult current CPT guidelines for appropriate modifier usage.
Medical necessity for code 99455 is established when a comprehensive evaluation is required to determine the extent of a patient's impairment related to work or medical disability.Documentation must clearly link the evaluation to the specific disability claim and justify the level of service provided.
The physician is responsible for conducting a thorough history and physical examination, establishing a diagnosis, assessing the patient's functional capacity, calculating impairment, developing a treatment plan, and preparing comprehensive documentation, including reports and certificates for insurance or legal purposes.The physician must justify medical necessity for the evaluation.
- Evaluation and Management > Special Evaluation and Management Services
- Evaluation and Management > Special Evaluation and Management Services
In simple words: The doctor performs a complete checkup to determine if your health issues are related to work or a disability. This includes a thorough history, exam, diagnosis, assessment of your abilities, a plan for future care, and detailed reports.
CPT code 99455 encompasses a detailed evaluation by a treating physician to assess work-related or medical disability.The evaluation involves a thorough medical history relevant to the patient's condition, a comprehensive physical examination, formulation of a diagnosis, assessment of the patient's capabilities and stability, calculation of any impairment, creation of a plan for future medical treatment, and completion of all necessary documentation, certificates, and reports.This service is distinct from routine office visits and necessitates extensive testing and individualized evaluation.
Example 1: A patient involved in a workplace accident undergoes a comprehensive evaluation by their physician to determine the extent of their injuries and their impact on their ability to return to work.This includes functional capacity evaluation and documentation for workers' compensation., A patient applying for disability insurance undergoes a detailed medical examination to assess their condition, including any limitations and the need for ongoing care.The physician completes the necessary forms and prepares a detailed report for the insurance company., A patient involved in a motor vehicle accident requires an evaluation to determine their lasting injuries and functional limitations. The physician assesses the severity of the injuries and the impact on their ability to perform daily activities. A detailed report is generated for legal purposes.
* Detailed medical history relevant to the disability claim.* Comprehensive physical examination notes with objective findings.* Diagnostic test results (e.g., imaging, laboratory).* Functional capacity evaluation (if applicable).* Assessment of capabilities and limitations.* Impairment rating and calculation.* Treatment plan outlining recommended therapies and interventions.* Completed forms and certificates as required by the insurance company or legal entity.* Detailed report summarizing the evaluation findings and conclusions.
** This code should only be reported when a comprehensive evaluation for work-related or medical disability is performed.It should not be used for routine office visits or simple paperwork completion.Proper documentation is essential for accurate coding and reimbursement.
- Revenue Code: Y2 (OTHER - NON-MEDICARE FEE SCHEDULE)
- RVU: Information not available in provided source.Consult the most recent CPT codebook or other official fee schedule for RVU data.
- Global Days : Information not provided.The global period would depend on the associated procedures, if any.
- Payment Status: Active
- Modifier TC rule: Not applicable. 99455 is a comprehensive evaluation service.
- Fee Schedule : Information not available in provided sources. Consult fee schedules and historical data from CMS or other relevant payers.
- Specialties:* Family Medicine* Internal Medicine* Occupational Medicine* Physical Medicine and Rehabilitation* Neurology* Orthopedics* Psychiatry (depending on the nature of the disability)
- Place of Service:Office, other outpatient settings.