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    v1.0.30
    OpenPayerBilling CodesWork Related or Medical Disability Evaluation ServicesCPT cpt-99455-work-related-or-medical-evaluation
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    CPT 99455: Work-Related or Medical Evaluation

    CPT code 99455 describes a provider-performed evaluation of a patient for work-related or other medical reasons, applicable to both new and established patients; service type: clinical evaluation/consultation; typical site of service: any outpatient or inpatient location, as the code applies irrespective of place of service.

    For related coverage guidance, see recent payer policy updates: Surgical Procedures, Outpatient Surgical Procedures - Site of Service, Site of Service Ambulatory Service Center (ASC) Select — Surgical or Diagnostic Procedures in Adults.

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    Clinical & Coding Specifications

    Clinical Context

    A 45-year-old construction worker presents for a work-related functional capacity evaluation requested by his employer and occupational health coordinator. The provider performs a focused assessment to determine work fitness, disability status, and any medical restrictions related to a shoulder strain sustained on the job two weeks prior. The visit includes review of medical records, a directed history, targeted physical examination of the musculoskeletal and neurologic systems, and documentation of work-related limitations and recommended restrictions. The provider completes required paperwork for return-to-work clearance and communicates findings to the employer and case manager. Services are furnished for either a newly referred worker or an established patient and may occur in an outpatient clinic, occupational medicine office, employer site visit, or inpatient setting when medically necessary.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    99456Work-related or medical disability examination by other than the treating physician; more than 45 minutesUsed for more extensive work-related evaluations when time and complexity exceed 99455 parameters.
    99204Office or other outpatient visit for the evaluation and management of a new patient, moderate complexityMay be used when a comprehensive new patient E/M is required in addition to work-related documentation.
    99214Office or other outpatient visit for the evaluation and management of an established patient, moderate complexityMay be used for established patients when a standard E/M visit is performed alongside work-related evaluation documentation.
    99454Work-related or medical disability examination by the treating physician; 21-40 minutes (hypothetical sequencing)Related shorter-duration work evaluations; applies when payer-specific time increments are defined.
    99456Work-related or medical disability examination by other than the treating physician; extended documentationPerformed when specialist or non-treating physician conducts extensive disability assessment and report generation.

    Related Modifiers

    5 rows

    ModifierDescriptionWhen to Use
    26Modifier 26 (Professional Component) identifies and bills only the professional portion of a split service — the physician’s interpretation, report, and medical judgment — when the technical…- Use CPT Modifier -26 when you are billing only the professional component (PC) of a split‑bill eligible service—i.e., you performed the physician interpretation, medical judgment and prepared a…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    55Modifier –55 indicates the billing provider furnished only postoperative management for a procedure that has a global surgical period. According to AAPC, this modifier is appended to the same CPT…- Use modifier -55 when billing the same CPT surgical code that has a 10- or 90-day global period and you, as a provider other than the original surgeon, furnished ONLY postoperative management (no…
    56Modifier ‑56 indicates the reporting provider furnished only the preoperative management for a surgical procedure and did not perform the intraoperative or postoperative care. It is used in…- Use Modifier -56 when a provider performs only the preoperative management in a split‑care situation (one physician manages preop care while a different physician performs the intraoperative…

    Related Provider Taxonomies

    8 rows

    Taxonomy Code
    207RH0000X
    207RG0300X
    207LP2900X
    207K00000X
    374K00000X
    3336I0012X
    261QC1500X
    207RA0401X

    Related Payer Policy Updates

    Specialty: General Surgery1 / 3

    10 rows

    PolicyPayerEffective Date
    Surgical ProceduresUnitedHealthcare2026-09-01
    Outpatient Surgical Procedures - Site of ServiceUnitedHealthcare2026-09-01
    Site of Service Ambulatory Service Center (ASC) Select — Surgical or Diagnostic Procedures in AdultsPremera Bluecross2026-09-01
    Site of Service Ambulatory Surgical Center (ASC) Select — Surgical or Diagnostic Procedures in AdultsPremera Bluecross2026-09-01
    Site of Service Ambulatory Service Center (ASC) SelectPremera Bluecross2026-09-01
    Site of Service Ambulatory Surgical Center (ASC) Select — Site of Service for Ambulatory Surgical Procedures (ASC Select)Premera Bluecross2026-09-01
    Site of Service Ambulatory Service Center (ASC) SelectPremera Bluecross2026-09-01
    Outpatient Surgical Procedures - Site of Servicesierra health and life2026-08-01
    Medical Necessity Guidelines — Inpatient Surgical CareMass General Brigham Health Plan2026-08-01
    Ambulatory Surgery Center (ASC) - Site of Care PolicyKaiser Permanente2026-08-01

    Related Codes

    CPT-99456-INDEPENDENT-WORK-RELATED-DISABILITY-EXAMINATION

    CPT 99456: Work-Related or Medical Disability Examination

    CPT-99457-REMOTE-PHYSIOLOGIC-MONITORING-MANAGEMENT

    CPT 99457: Remote Physiologic Monitoring Management with Interactive Communication

    CPT-99458-REMOTE-PHYSIOLOGIC-MONITORING-ADDITIONAL-20-MIN-STAFF-TIME

    CPT 99458: Remote Physiologic Monitoring, Additional 20 Minutes

    CPT-99459-PELVIC-EXAMINATION-WITH-EVALUATION-MANAGEMENT

    CPT 99459: Pelvic Exam with Evaluation and Management

    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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