99243 CPT Code (2022) | Description & Clinical Examples

99243 CPT code is an outpatient office consultation code of moderate complexity; the CPT editorial panel is responsible for maintaining this CPT.

Be aware that CPT 99243 was revised on 01-01-2023. This article is about the previous code description.

Summary

As per this CPT description, the provider should spend at least 40 minutes face-to-face with the patient or family.

Only Part B enrolled providers are eligible to get reimbursements for this service. A consultation note is similar to an E&M letter.

The requirement of all three critical components (history, examination, and medical decision-making) of E&M is a prerequisite for an appropriate level of CPT code selection.

As per the AMA descriptor, the CPT 99243 presents the history and exam as detailed and the medical decision-making as moderate complexity.

Coders should pay appropriate attention while assigning the consult code based on the details listed in the three critical components mentioned above.

All of the above-mentioned vital components should be in a note as if any of the components or subcomponents is missing, which will negatively affect code selection.

Description Of The 99243 CPT Code

99243 CPT code falls in the middle of the consultation codes series concerning the severity and time spent providing care coordination and other providers or qualified health care professionals.

The official description of CPT 99243 is: “Office consultation for a new or established patient, which requires these 3 key components:

• A detailed history;
• A detailed examination; and
• Medical decision making of low complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are of moderate severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.”

The consultation note must include the critical components as described below:

1. History

• History of present illness

• Review of systems

• Past family and social history

In the history of present illness, the provider must clearly mention the reason for consultation on a note.

The reason behind consult allows the whole process to get smooth.

The review of the system part consists of some simple questions about body systems that a patient can answer quickly.

If the patient cannot answer those questions due to any medical condition, the physician may consider this part complete.

A review of the system should be confused with an examination as both portions are similar but used for different purposes.

2. Examination

In this portion, the consulting physician has to examine the patient’s body system in detail to make an opinion about the disorder.

The provider evaluates all plans one by one. He can determine one method, in fact, as per the patient-specific requirements.

3. Medical Decision Making

Medical decision-making is an essential part of a consult note.

Usually, this part is wholly dependent upon why the patient needs consultation.

Related Codes

Besides CPT code 99243, four other CPT codes fall in the consultation category starting from CPT 99241 – CPT 99245.

1. CPT 99241 presents the consultation for self-limiting or minor disorders.
2. CPT 99242 presents the consultation for problems of low severity.
3. CPT code 99243 presents the consultation for problems of moderate severity.
4. CPT 99244 presents the consultation for problems of high severity.
5. CPT 99245 is used for consultation for moderate to high-severity problems.

Claim Processing

Three R’s criteria (Request, Render, report back) are essential in claim processing, and one must fulfill them for a consultation. All the points are mentioned below in detail.

Request

One must generate a separate request to refer for consultation from the principal or referring physician to other physicians or qualified healthcare professionals.

The consulting physician must include the referring physician’s name in his note.

Some insurances, including Medicare or Medicaid, may not pay for the consult code if the referring physician’s name is unavailable in the consult note.

It is because it is easy for insurance companies for claim screening purposes.

A physician’s reputation is also vital in determining the services’ legitimacy.

Render

This part presents the body of a consult note, which should include the advice or opinion of the consulting physician on the problems for which the physician initiates a consultation request.

The consulting physician can order diagnostic services to analyze the disorder further and suggest corrective actions.

Report Back

When the consulting physician reports back to the principal or referring physician, he must include the recommendation for treatment in the medical decision-making portion of his note.

For outpatient consults, one must present the report separately. But the shared medical record can do this in an in-patient setting.

Billing Guidelines & Reimbursement

The CPT code 99243 is used to represent second-opinion visits.

Consultation is an assessment and management service administered by a physician at the request of a separate physician or another appropriate source, either to recommend treatment for a particular condition or problem or to define whether they should be responsible for ongoing treatment.

It is not used as a code for evaluation and management, or is it the counselling associated with it.

When coding an evaluation and management (E / M) service as a query is one of the most commonly asked questions is how to find out if an E / M service is a query.

The discreet contrast between a consultation and an outpatient visit is that the consultation is given by a doctor whose judgment or advice regarding the assessment and/or management of a particular problem is requested by another doctor.

A study visit is considered a consultation only if the following principles are met for the use of a consultation CPT code:

1. The consultation is carried out at the request of another professional or appropriate source that requires an opinion regarding the E / M of a problem.
2. The visit request and the reason for the request must be recorded in the patient’s medical history.
3. The professional must draw up a written review report delivered to the attending physician after-consultation.

Suppose all the previous requirements are not acquired. In that case, the appropriate office or another outpatient (CPT code 99201 – 99215) or hospital inpatient (CPT code 99221 99223) E / M service may be reported instead of a consultation CPT code.

The following are a few guidelines to help you determine if you are entitled to use of a consultation CPT code 99241 – 99245.

The documentation should include evidence of:

• A third party mandated consultation.
• Documentation of a request for a consultation from an appropriate source.
• Documentation of the requirement for consultation in the patient’s medical history.

Only one consultation for each consultant.

Provision by a physician or qualified non-physician practitioner with the opinion, advice, recommendation, suggestion, direction or counsel is ask for treatment and evaluation.

Recommendations of a patient for that individual’s specialty in a certain medical department are beyond the scope of knowledge of the requesting physician or qualified non-physician.

Provision of a written report of findings or recommendations from the consultant to the referring physician or qualified non-physician.

Consultation CPT codes may not be billed repeatedly or when the patient or family prompts the consultation.

The place of service (POS) for CPT code 99243 should be 11 (OF) while billing. The same specialty provider can perform this service only once per day.

Suppose the provider needs another opinion or consultation from a different specialty provider.

In that case, he can bill out-patient consult twice on the same day in a separate claim under secondary consulting physician NPI.

The payment schedule depends on the insurance companies; commercial insurances accept out-patient consultation codes.

But government insurances (Medicare or Medicaid) have a strict payment policy. They do not accept outpatient consults (CPT 99241 – CPT 99245).

So, alternate CPT codes replacing consultation codes such as routine office visits are available to get reimbursements for Medicare or Medicaid insurance.

According to the comprehensive component edit policy, the coder can bill the outpatient consultation twice daily. This CPTs MUE adjudication criterion is 3 – 0.

Outpatient consult codes (CPT 99241 – CPT 99245) are also unrestricted for consultation provided to the patients in outpatient hospital departments, i.e., Emergency department and Observation.

The selection of the out-patient consultation code level (CPT 99241 – CPT 99245) depends upon the overall severity of the encounter.

For government insurance, as they do not accept consultation codes, we have to use outpatient routine evaluation and management codes (CPT 99201 – CPT 99215).

While billing the second consultation of the same provider for government insurance, the coder must choose the CPT codes from the established outpatient category of routine visits.

The facility charge of CPT code 99243 is $95. The nonfacility cost allowed for this CPT is $121.47.

The consultation code service charges may vary per individual insurance’s contractual obligation.

How To Use Modifiers With The 99243 CPT Code

Only a few modifiers can go with the 99243 CPT code and other general evaluation and management CPT codes.

Each of the modifiers is explained below in detail. The coder should pay appropriate attention while appending these modifiers with CPT 99243.

Their misuse or overuse can lead to comprehensive audits, and practice may face severe penalties.

The practical examples and applications of modifiers are 24, 25, 57.

Modifier 24

Append modifier 24 with CPT code 99243 in cases where the encounter for consultation falls in the global period of any surgical procedure.

The global period of any specific technique can be 10 – or 90 – days, as the coding manual states. All the major surgical procedures have a global period of 90 – days, such as lumpectomy.

All the minor surgeries have a global period of 10 – days, i.e., I&D (Incision and Drainage).

If the patient receives any consultation during that global period, the claim is ready for submission with modifier 24.

Modifier 57

Append modifier 57 with 99243 CPT code when the physician has decided to perform surgery on the same consultation day.

Same day and a day before surgery are included in the global surgical package for minor and major surgical procedures.

So, insurance may not reimburse it separately and considers it a part of the surgical procedure.

Modifier 25

Modifier 25 is the most commonly used modifier applied to general evaluation and management codes.

It also applies to consultation codes when a physician performs separately identifiable services on the same day of the encounter, such as minor surgical procedures.

When the coder does not append modifier 25, the insurance will consider consulting code inclusive of the other service performed on the same day and pay it separately.

Modifier AQ

If a physician provides services in unlisted health professional shortage areas, one must append modifier AQ to be reimbursed at higher rates.

As per the government policy, insurance companies reimburse the services more in rural than urban areas.

Telehealth Modifiers

Telehealth modifiers such as 95 and GT are also applicable with CPT 99243 when the provider provides the service via telecommunication.

According to the latest release by AMA, the POS will be 02 for all outpatient consultations.

Selecting an appropriate modifier per the situational requirement is the key to maximizing the first-pass ratio of claims.

Billing Examples

The following billing examples are cases when CPT 99243 may be used.

Example 1

Sixty-five years old females visit Dr. Lee, her primary care physician’s office, to evaluate the complaints about generalized weakness, right upper quadrant abdominal pain, and frequent urination.

After a complete examination, her PCP requests a second opinion from a Gastrointestinal Specialist, Dr. Smith as she wants to suggest the medication after consulting the physician’s remarks.

The patient’s insurance is Medicare.

The coder will generate two claims on the same DOS in the above example.

The coder or biller bills with routine out-patient evaluation and management codes range from CPT 99201 to CPT 99215.

The consulting physician provides the services for the first time to this patient.

As the insurance is Medicare, he will submit the claim with a new out-patient evaluation and management code (CPT 99201 – CPT 99205) to get the reimbursements for his services.

Example 2

A 45 – years old diabetic male visits Dr. pakora in the office to discuss his health issues. He is experiencing generalized weakness, fatigue, nausea, and dull pain in the left shoulder due to a frozen shoulder.

After a complete examination, his primary care physician requests a second opinion from Dr. Abruzzi; is a pain management specialist.

He needed another thought from a specialist before suggesting any medications for shoulder pain. The patient’s insurance is commercial.

The coder or biller will generate two claims on the same DOS in the above example.

The coder bills with routine outpatient evaluation and management codes range from CPT 99212 to CPT 99215.

The consulting physician will claim his services with a CPT code ranging from CPT 99241 to CPT 99245.

Example 3

Initial office consultation for a 60-year-old male with avascular necrosis of the left femoral head with increasing pain. (Orthopaedic Surgery)

Example 4

Office consultation for a 31-year-old woman complaining of palpitations and chest pain; her internist had described a mild systolic click. (Cardiology)

Example 5

Office consultation for a 65-year-old female with persistent bronchitis. (Infectious Disease)

Example 6

Office consultation for a 65-year-old man with chronic low-back pain radiating to the leg. (Neurosurgery)

Example 7

Office consultation for a 23-year-old female with Crohn’s disease not responding to therapy. (Abdominal Surgery/Colon & Rectal Surgery)

Example 8

Office consultation for a 25-year-old patient with symptomatic knee pain and swelling, with torn anterior cruciate ligament and/or torn meniscus. (Orthopaedic Surgery)

Example 9

Office consultation for a 67-year-old patient with osteoporosis and mandibular atrophy about reconstructive alternatives. (Oral & maxillofacial Surgery)

Example 10

Office consultation for a 39-year-old patient referred at a perimenopausal age for irregular menses and menopausal symptoms. (Obstetrics & Gynaecology)