CPT 99455E&M

Work related disability exam

CPT 99455 is used when a doctor performs a comprehensive examination to evaluate whether a work-related injury or illness has caused a disability. This is typically done at the request of an employer, insurance company, or workers' compensation board to determine disability status and work capacity.

Showing rates for

National Average

Base Medicare rate

$0.00

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

PE RVU (NF)

MP RVU

Total RVU

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Do not bill Medicare for 99455 as it is non-covered; always verify the appropriate third-party payer (workers' compensation, disability insurer, or employer)
Impact: Prevents automatic denials and delayed payment; workers' comp fee schedules often pay $500-$1500 depending on complexity and state
Obtain pre-authorization from the requesting entity and confirm the specific fee schedule or contracted rate before performing the examination
Impact: State workers' compensation rates vary 200-300% between jurisdictions; pre-authorization ensures payment commitment
Bill the requesting party directly (employer, insurance carrier, or attorney) rather than the patient, and clearly document who ordered the examination
Impact: Prevents patient balance billing issues and ensures proper payment source; improves collection rate by 60-80%
Use detailed narrative reports with specific functional capacity assessments, causation analysis, and disability ratings as required by the requesting entity
Impact: Comprehensive documentation justifies higher complexity payments and reduces disputes; may increase reimbursement by 20-40% for complex evaluations
Consider using state-specific workers' compensation codes when applicable instead of CPT 99455, as some jurisdictions have unique coding requirements
Impact: Some states require proprietary codes or have fee schedules that pay 30-50% higher for state-specific codes
Clearly separate any treatment services from the disability evaluation; bill evaluation and treatment encounters separately to avoid bundling disputes
Prevents downcoding or denial of legitimate treatment services that should be billed under standard E/M codes

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Frequently asked questions

Does Medicare cover CPT code 99455?

No, Medicare does not cover CPT 99455. This code is specifically for work-related disability examinations, which are excluded from Medicare coverage. Payment comes from workers' compensation carriers, disability insurers, employers, or other third-party payers who requested the examination.

What is the difference between CPT 99455 and regular E/M codes?

CPT 99455 is used exclusively for independent disability evaluations requested by third parties to determine work capacity and disability status. Regular E/M codes (99202-99215) are used for treatment-focused patient encounters. The key distinction is that 99455 is an evaluative, non-treatment service performed at the request of someone other than the patient, typically for legal or administrative purposes.

Who pays for CPT 99455 services?

CPT 99455 is typically paid by workers' compensation insurance carriers, disability insurers, employers, attorneys, or government agencies that request the independent medical examination. The requesting entity, not the patient or Medicare, is responsible for payment. Fee schedules vary significantly by state workers' compensation programs and individual payer contracts.

Can I bill 99455 and an E/M code on the same day?

Generally no, you should not bill both 99455 and a standard E/M code for the same patient encounter. If you are performing an independent disability evaluation (99455), you are not the treating physician for that visit. However, if you provide separate, distinct treatment services on a different date or for an unrelated condition, those would be billed with appropriate E/M codes.

What documentation is required for CPT 99455?

Documentation must include a comprehensive narrative report with medical history, detailed physical examination, review of all relevant medical records, functional capacity assessment, causation analysis, maximum medical improvement determination, permanent impairment rating, work restrictions, and specific answers to all questions posed by the requesting entity. Most payers require reports following AMA Guides or state-specific disability rating systems.

How much does CPT 99455 reimburse?

Reimbursement varies widely as Medicare does not cover this code. Workers' compensation fee schedules typically range from $500 to $1,500 depending on the state, complexity, and whether additional testing or specialized assessments are included. Some states use multipliers of the Medicare rate, while others have flat fees. Private disability insurers negotiate individual rates. Always verify the applicable fee schedule before performing the examination.

Do I need to be certified to bill CPT 99455?

While CPT 99455 does not require specific certification from a coding standpoint, many workers' compensation programs and disability insurers prefer or require physicians to have training in independent medical examinations, disability evaluation, or certification in using the AMA Guides to the Evaluation of Permanent Impairment. You typically cannot be the patient's treating physician and must maintain independence from the treatment relationship.