CPT 99456E&M

Disability examination

CPT code 99456 is used for medical examinations performed solely to determine a person's disability status, such as for insurance claims, workers' compensation, or Social Security disability applications. These exams evaluate medical conditions but are not for treatment purposes.

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

Establish fee schedule and collect payment upfront since Medicare assigns $0 reimbursement and most insurance considers this non-covered
Impact: Prevents complete revenue loss; typical fees range $300-$800 depending on examination complexity and report requirements
Create separate contract with requesting entity (attorney, insurance carrier, employer) before performing examination
Impact: Ensures payment responsibility is established; reduces collection issues by 90%
Use appropriate workers' compensation or liability carrier codes instead of 99456 when applicable to state-specific programs
Impact: Many states have specific WC fee schedules that reimburse at higher rates than standard disability exam fees
Document that examination is non-therapeutic and patient was informed this is not a treatment visit
Impact: Prevents confusion with E&M codes and protects against fraud allegations for billing covered services
Include comprehensive written report as part of service; consider separate fees for addenda or testimony
Impact: Standard reports justify base fee; additional services can generate $200-$500 supplemental revenue
Do not bill Medicare or Medicaid as primary; code will automatically deny and may trigger audit flags
Impact: Avoids compliance issues and unnecessary claim denials that waste administrative time

Common denials

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Frequently asked questions

Does Medicare cover CPT code 99456 for disability examinations?

No, Medicare does not cover CPT 99456. The 2025 Medicare reimbursement rate is $0 with 0 RVUs assigned. This code represents administrative examinations for disability determination, which Medicare considers non-covered services. Payment must come from the requesting entity, patient, or alternative payer.

Who pays for CPT 99456 disability examination services?

Payment typically comes from the entity requesting the examination: Social Security Administration, workers' compensation carrier, disability insurance company, attorney, or employer. Physicians should establish payment arrangements before performing the exam, as traditional health insurance rarely covers these administrative evaluations.

What is the typical fee for a 99456 disability examination?

Fees vary widely from $300 to $800 or more, depending on examination complexity, report requirements, and geographic location. Since Medicare assigns no value, physicians set their own fee schedules. Workers' compensation and independent medical examinations often command higher fees based on state schedules or negotiated contracts.

Can I bill both 99456 and a regular E&M code on the same day?

Generally no. CPT 99456 is specifically for non-therapeutic disability evaluations. If you provide actual medical treatment during the same encounter, you should bill the appropriate E&M code instead. Billing both for the same encounter could be considered duplicate billing unless they are clearly separate, documented encounters for different purposes.

What documentation is required to bill CPT 99456?

Required documentation includes the written examination request from the requesting entity, patient notification that this is a non-treatment exam, comprehensive medical history and physical examination findings, functional capacity assessment, review of medical records, and a detailed written report addressing the specific disability questions. Documentation must clearly show no therapeutic intervention was provided.

Is CPT 99456 covered by workers' compensation insurance?

Workers' compensation may cover disability examinations, but most states have specific workers' compensation codes and fee schedules rather than using CPT 99456. Check your state's workers' compensation billing guidelines, as they often require state-specific codes for independent medical examinations and disability evaluations with different reimbursement structures.

How do I code a Social Security disability examination?

CPT 99456 can be used for Social Security disability examinations, but payment comes from the Social Security Administration through their contracted examination program, not through Medicare. Physicians must be enrolled in the SSA consultative examination program with pre-established fees. Do not submit these claims to Medicare as they will deny.