2025 CPT code 99456
(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
Work-related or medical disability examination by a physician other than the treating physician, encompassing medical history, examination, diagnosis, assessment of capabilities, treatment plan, and documentation.
Modifiers may be applicable depending on the circumstances of the encounter.Consult the CPT manual and payer guidelines for appropriate modifier usage.
Medical necessity is established by the presence of a work-related injury or illness requiring evaluation to determine the extent of disability, the impact on the patient's ability to work, and the development of an appropriate treatment plan.Documentation must support the need for this evaluation by an independent physician and must be consistent with the specific requirements of the insurance company or disability agency involved. Payer policies will vary.
The physician performing this evaluation is responsible for obtaining a thorough history, performing a comprehensive examination, generating a diagnosis, assessing the patient's functional limitations, and creating a treatment plan.They must also complete the necessary documentation required by insurance companies or disability agencies.
In simple words: A doctor who isn't your regular doctor examines you because of a work injury or illness to see how your condition affects your ability to work. They take your history, examine you, diagnose the problem, assess your work capabilities, and provide a treatment plan. They also complete necessary paperwork for insurance claims or disability benefits.
This CPT code (99456) represents a comprehensive work-related or medical disability examination performed by a physician who is not the patient's treating physician.The service includes a detailed medical history relevant to the patient's condition, a thorough physical examination tailored to the condition, establishing a diagnosis, assessing the patient's functional capabilities and stability, determining the extent of impairment, creating a plan for future medical management, and completing all necessary documentation, certificates, and reports.This code should not be used if the physician is the patient's treating physician; in that case, 99455 should be used instead.
Example 1: A construction worker injured on the job undergoes an independent medical examination (IME) to assess the extent of their injury and determine their ability to return to work.This IME is conducted by a physician who is not their primary care doctor and is billed using CPT code 99456., An employee experiences a work-related illness, and their employer's insurance company requires a comprehensive evaluation from an independent physician to determine their diagnosis, prognosis, and long-term disability status. This evaluation, performed by a physician unaffiliated with the patient's regular care team, is billed using CPT code 99456., A patient is applying for long-term disability benefits due to a pre-existing condition. As part of the application process, an independent medical evaluation is required, and a physician outside of the patient's existing care team performs the assessment and completes the necessary documentation, billed with CPT code 99456.
Detailed medical history, including the onset, nature, and progression of the work-related injury or illness; a complete physical examination relevant to the alleged condition; diagnostic test results and other relevant medical records; a clear and concise assessment of the patient's functional abilities and restrictions; a treatment plan outlining recommendations for care and rehabilitation; and completed forms and reports required by the relevant insurance or disability agency.
** This code is used for independent medical evaluations (IMEs) performed by a physician who is not the patient's treating physician.Accurate documentation is crucial for proper reimbursement.Always check payer-specific guidelines for billing requirements.
- Revenue Code: Y2 (OTHER - NON-MEDICARE FEE SCHEDULE)
- RVU: Information not available in provided sources.RVUs vary by location and payer.
- Global Days: Not applicable. This is not a surgical procedure.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Fee Schedule: Information not available in provided sources. Fee schedules are location and payer specific.
- Specialties:Occupational Medicine, Physical Medicine and Rehabilitation, Orthopedics, and other specialties depending on the nature of the work-related injury or illness.
- Place of Service:Office, other outpatient settings.