99241 CPT code

99241 CPT Code (2022) Description, Guidelines, Reimbursement, Modifiers & Examples

99241 CPT code reports for service when the physician or other qualified healthcare professional performs office and other outpatient consultation services to new or established patients. It includes all three components of evaluation and management settings. 

99241 CPT Code Description

Office and other outpatient consultation service codes describe the physician seeing the patient upon the request of the primary care provider regarding diagnosis and treatment or determination to accept the transfer of care of a patient. 

Another appropriate source may also request consultations; for example, a third-party payer may request a second opinion. The consultation request must be the document in the medical record and a written report of the consultation findings. 

The physician consultant can initiate diagnostic or therapeutic services during the same encounter or a follow-up visit during a consultation. The consultation service may report separately in conjunction with Other separately reportable procedures. 99241 CPT code does not differentiate between new or established patients. 

The most basic service, 99241 CPT code, describes a problem-focused history and exam with straightforward medical decision-making encompassing approximately 15 minutes of face-to-face time with the patient and-or family discussing a minor or self-limiting complaint. 

cpt code 99241

The mid-level services describe problems involving an expanded problem-focused history and exam or a detailed history and exam as represented by 99242 and 99243, respectively. Medical decision-making for 99242 is the same as a level one visit (straightforward) and assigns low complexity for the level three service (99243). 

At these service levels, the encounter can involve the face-to-face time of 30 (99242) to 40 (99243) minutes involving minimal to low severity concerns. The last two levels of service in this category represent moderate to high-severity problems, and both services apply comprehensive history and examination components.

The differentiating factor between the two levels is the medical decision-making; code 99244 involves moderate complexity MDM and approximately 60 minutes of face-to-face time with the patient and-or family, while the highest level of service in this category, 99245, involves MDM of high complexity and approximately 80 minutes of face-to-face time.

99241 cpt code 2021

99241 CPT code reports for service when the physician or other qualified healthcare professional performs office and other outpatient consultation services to new or established patients. It includes all three components of evaluation and management settings. 

Services are reported based on meeting all three key components (history, exam, and medical decision-making [MDM]) within each level of service.

The following are essential components when CPT code 99241 bills:

Typically requires 15 minutes of total time spent by the physician face-to-face with the patient or patient’s family if code selection is time-based.

A problem-focused history

A problem-focused examination

Straight-forward MDM

Presenting problem is self-limited and minor

The amount of time spend determines by a person’s condition and treatment needs.

Counseling and-or coordination of care with other physicians, other qualified health care professionals, or agencies consistently provides the nature of the problem(s) and the patient’s and-or family’s needs.

cpt 99241

99241 CPT Code Reimbursement 

A maximum of zero units can be a bill on the same service date of CPT code 99241. In contrast, the three units allow when documentation supports the medical necessity of the service.  

The cost and RUVS of 99241 CPT code are $34.28 and 0.99057 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 99241 are $51.36 and 1.48407 when performed in the non-facility.

The performing provider may report telemedicine services by adding modifier 95 to the CPT code 99241. Services at the origination site report with HCPCS Level II code Q3014.

99241 CPT Code Modifiers

The following is the list of modifiers when 99241 CPT code bills:

25, 24, 27, 95, 57, 99, AR, AQ, AI, CS, CR, CC, EY, ET, G0, GC, GA, GJ, GK, GT, GQ, GR, GU, GX, GY GZ, KX, TH, Q5, Q6, TH

The most frequent modifiers used with CPT 99241 are 24, 25, and 95.

Modifier 25 will be appended with 99241 CPT code when services perform in conjunction with other services not customarily billed together on the same day. 

Modifier 24 appends with CPT 99241 when service performs in the post-operative period with unrelated procedures or services.

Modifier 95 will be attached to CPT code 99241 if the service provides during a telehealth visit.

Modifier 57 will be attached to 99241 CPT code if physicians plan to do surgery on the same service date when the E/M visit bills.

If physicians believe that Medicare will deny such service, reporting with a GA modifier is appropriate. The beneficiary must sign an Advance Beneficiary Notification (ABN), and CPT 99241 must apply the GA modifier to that service.

99241 CPT Code Billing Guidelines

Documentation should support the medical necessity of service. It reflects that service is medically necessary and appropriate.   

CPT code 99241 requires 3 out of 3 components which are as follows: 

 A problem-focused history: It requires at least 1 HPI element, 1 ROS system, and may or may not history components (PFSH).

A problem-focused examination requires one system per 95 documentation and one with no bullets required as 97 documentation. 

Straightforward MDM: It requires at least 2 out of three components of MDM that must meet on that basis of risk, diagnostic or treatment, Data management services like Medicine, Laboratory, Medicine, Medicine, Medicine, review, counseling, Interpretation of services. 

If time mentions in the medical notes, then it is appropriate to bill based on time instead of MDM, which typically requires 15 minutes of consultation with the patient by the consultant.

Consultation CPT Code 99241 does not accept by Medicare. It is appropriate to the bill as office or other outpatient hospital visit codes (99202-99499)

If the patient’s diagnosis and the problem assume before or at the initial evaluation, consultation CPT codes do not report separately.

99241 CPT code may not report for inpatient consultation services. The Inpatient consultation services bill with 99251-99255 CPT codes. While the outpatient hospital or office visits bills with E/M CPT codes (99202-99215)

Emergency CPT codes (99281-99285) are separately reportable when performed with CPT 99244.

If consultation service prompts by the patient/family, CPT 99241 is not appropriate to the bill. It may report with office, domiciliary/rest home, or home visit CPT codes (99202-99215, 99324-99337, 99341-99350).

Q3014 is applicable when the hospital provides telemedicine service as an origin site to other outpatient hospital patients.

All outpatient consultations furnish in the office, outpatient or other ambulatory facilities, domiciliary/rest home, emergency department, patient’s home, and hospital observation

CPT code 99241 includes the following services:

Documentation is needed for consultation requests and must be in the patients’ medical records. One provider can bill only one consultancy in one day.

Provision by the physician or qualified nonphysician practitioner whose suggestion, direction, or counsel, advice, opinion, recommendation, etc., is requested for evaluating/treating patients if the primary care provider or attending provider does not have knowledge and expertise in that specialty

Provision authored report, findings/recommendations from consultant to referring physician

Modifier 32 appends with 99241 CPT code for the third-party mandated consultation.

99241 CPT Code Examples

The following are the examples when CPT code 99241 bills:

Example 1

An eighteen-year-old male with no past medical history now presents with sutures removal. He did cut his hand seven days ago and got three staples. The patient did not take any medication for pain. 

The physician performed a limited physical exam, and it showed unremarkable findings. The patient has no pain in both upper extremities. The physician did not see any swelling or infection in his hand.

Physicians discussed how to prevent infection and did not prescribe any medicine to the patient.

Example 2

A Thirty-year-old male with no past medical history now presents with a follow-up of headache. He has no pain in the head. The patient did take his medication for pain. 

The physician performed a limited physical exam, and it showed unremarkable findings. The patient has no pain in the head. He did not see any other abnormal results during the head exam.

Physicians discussed how to prevent headaches and did not prescribe any medicine to the patient.

Example 3

A forty-six-year-old male with no past medical history now presents with the follow-up of an insect bite on his face. The patient is not feeling irritation at the site of the insect bite. The patient did take his medication for pain. 

The physician performed a limited physical exam, and it showed unremarkable findings. The patient has no pain at the site. The physician did not see any swelling or infection on his face.

Physicians discussed how to prevent infection and did not prescribe any medicine to the patient.

Example 4

A forty-seven-year-old male with no past medical history now presents with the follow-up of a healing wound on his right foot. The patient is not feeling irritation at the site wound. The patient did take his medication for pain. 

The physician performed a limited physical exam, and it showed unremarkable findings. The patient has no pain at the site. The physician did not see any swelling or infection on his face.

Physicians discussed how to prevent infection and did not prescribe any medicine to the patient.

Example 5

A forty-nine-year-old male with no past medical history now presents with the follow-up of skin allergies. The patient is not feeling irritation on the skin. The patient did take his medication for pain. 

The physician performed a limited physical exam, and it showed unremarkable findings. The patient has no irritations on the skin. The physician did not see any swelling or infection on his face.

Physicians discussed how to prevent infection and did not prescribe any medicine to the patient.

Example 6

Initial office consultation for a 40-year-old female in pain from blister on lip following a cold. (Oral & Maxillofacial Surgery)

Example 7

Initial office consultation for a 62-year-old construction worker with olecranon bursitis. (Orthopaedic Surgery)

Example 8

Office consultation with 25-year-old postpartum female with sever symptomatic haemorrhoids. (Colon & Rectal Surgery)

Example 9

Office consultation with 58-year-old male, referred for follow-up of creatinine level and evaluation of obstructive Uropathy, relieved two months ago. (Nephrology)

Example 10

Office consultation for 30-year-old female tennis player with sprain or contusion of the forearm. (Orthopaedic Surgery)

Example 11

Office consultation for a 45-year-old male, requested by his internist, with asymptomatic torus palatines requiring no further treatment. (Oral & Maxillofacial Surgery)

CPT 99241 Consultation Code

The following is for CPT codes 99241 – 99245. Consultation coding is used to represent second opinion visits.

Consultation is a class of assessment and management service given by a physician at the request of a second physician or other necessary source. These are either to recommend treatment for a particular illness or problem, or to resolve whether he should be responsible for continuous treatment of the patient or for the care of a specific condition or problem.

It does not serve as a code of conduct for assessment and management, or related advice.

Effective from 1st October 2017, United Healthcare will no longer reimburse for consulting services represented by CPT codes 99241 – 99245 and CPT codes 99251 – 99255.

United Healthcare reimburses for the needed assessment and administrative process (E / M) code that explains the practice visit, the hospital care codes reported in lieu of a counseling service regulation.

Cigna is the most recent payer to declare that consulting services will no longer be reimbursed as of 19th October 2019.

Consulting services formerly represented by CPT codes 99241 – 99245 and CPT codes 99251 – 99255 must be provided using the Evaluation and Administrative Procedure Code (E / M) corresponding to the practice visit, hospital care, care center, home service, or home / nursing care.

2021 Updates For Reporting Consultation Codes

If you are reporting an inquiry (CPT 99241 – 99245 and CPT 99251 – 99255) to a payer that recognises the tips, use the 1995 – 1997 guidelines to choose a level of service.

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