Basics of CPt code 99244, 99242, 99243 and 99245
For the Current Procedural Terminology (CPT) 2023 code set, the E/M consultation subsection guidelines and code descriptors were significantly revised as part of the continuous effort to simplify administrative processes when providing E/M services. A consultation is defined in the CPT 2023 code set as “a type of evaluation and management service provided at the request of another physician, other qualified health care professional, or appropriate source to recommend care for a specific condition or problem.” These services are used across numerous care settings, such as, but not limited to, the office or other outpatient setting, including the physician’s office, the hospital inpatient or observation setting, or a nursing facility. This article will review the changes in the E/M Consultations subsection for 2023. CPT code 99244, 99242, 99243 and 99245 are being revised from this year.
Guidelines changes for CPT code 99244, 99242, 99243 and 99245
Changes made in the guidelines for consultation services include the addition of “other qualified health care professional (QHP).” It remains the case that consultations initiated by the patient or the patient’s family member cannot be reported using consultation codes; these services should be reported with other appropriate E/M service codes, such as initial hospital or observation care setting codes or the nursing facility codes. A written report describing the consultant’s services should be communicated to the physician, other QHP, or other appropriate source. The guidelines no longer address the topic of documentation in the patient’s medical record, and they have been updated to direct users to the appropriate subsection for initial hospital inpatient or observation care or initial nursing facility care services when a patient is admitted during an encounter in another setting. Finally, any follow-up care provided by the consultant during the same admission is not considered an additional consult service; instead, it may be reported using codes for subsequent care for established patients, based on the site of service and the rules for that specific site.
Description of CPt code 99244, 99242, 99243 and 99245
Office or other outpatient consultation service codes describe encounters where another qualified clinician’s advice or opinion regarding diagnosis and treatment is rendered at the request of the primary treating provider. Consultations may also be requested by another appropriate source (e.g., a third-party payer may request a second opinion). The request for a consultation must be documented in the medical record, as well as a written report of the consultation findings. During the course of a consultation, diagnostic or therapeutic services may be initiated at the same encounter or at a follow-up visit. Office or other outpatient sites include the physician’s office, a home or residence, or the emergency department. For subsequent office or outpatient encounters for the same patient. Consultation codes do not differentiate between new or established patients. All services require a medically appropriate history and/or examination. Code selection is based on the level of medical decision making (MDM) or total time personally spent by the physician and/or other qualified health care professional(s) on the date of the encounter. Factors to be considered in MDM include the number and complexity of problems addressed during the encounter, amount and complexity of data requiring review and analysis, and the risk of complications and/or morbidity or mortality associated with patient management.
CPT code 99242 is reported for a visit that entails straightforward MDM. If time is used for code selection, a total time of 20 minutes must be met or exceeded on the day of the encounter.
CPT code 99243 is reported for a visit requiring a low level of MDM or meeting or exceeding 30 minutes of total time;
CPT code 99244 is reported for a moderate level of MDM or meeting or exceeding 40 minutes of total time; and
CPT code 99245 is reported for a high level of MDM or meeting or exceeding 55 minutes of total time.
When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.
When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
99244 – Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.
99245 – Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and high level of medical decision making.
When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded.
