99245 CPT Code (2022) | Description, Guidelines, Reimbursement, Modifiers & Examples
99245 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.
Be aware that CPT code 99245 has been revised on the 1st of January, 2023. This article is about the previous version of the code description.
Description Of The 99245 CPT Code
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 documented 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. 99245 CPT code does not differentiate between new or established patients.
The most basic service, 99241, 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.
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 CPT code, involves MDM of high complexity and approximately 80 minutes of face-to-face time.
The official description of CPT code 99245 is:
“Office consultation for a new or established patient, which requires these 3 key components:
- A comprehensive history;
- A comprehensive examination; and
- Medical decision making of high 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 to high severity. Typically, 80 minutes are spent face-to-face with the patient and/or family.”
CPT 99245 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.
The following are essential components when CPT 99245 bills:
Typically requires 80 minutes of the total time the physician spends face-to-face with the patient or patient’s family if code selection is time-based.
- A comprehensive history
- A comprehensive examination
- Medical decision-making of high complexity
- Doctor consultation, one plus hour
- Presenting problem is moderate to high severity
- The amount of time spent 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.
Reimbursement
A maximum of zero units can be a bill on the same service date of 99245 CPT code. In contrast, the three units allow when documentation supports the medical necessity of the service.
The cost and RUVS of CPT 99245 are $200.96 and 5.80713 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 99245 are $238.37and 6.88813 when performed in the non-facility.
The performing provider may report telemedicine services by adding modifier 95 to the 99245 CPT code—services at the origination site report with HCPCS Level II code Q3014.
Billing Guidelines
Documentation should support the medical necessity of service. It reflects that service is medically necessary and appropriate.
CPT 99245 requires 3 out of 3 components which are as follows:
A comprehensive history: It requires at least 4 HPI elements, 10 ROS systems, and two history components are needed 2 out of 3 parts (PFSH).
A comprehensive examination requires ten plus systems per 95 documentation and eight plus systems with four bullets as 97 documentation.
High complexity 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, and 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 99245 CPT code 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.
CPT 99245 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 99245 CPT code.
If consultation service prompts by the patient/family, CPT 99245 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
99245 CPT code includes the following services:
Documentation for consultation requests must be in the patient’s medical records. One provider can bill only one consultancy in one day.
Provision by the physician or qualified nonphysician practitioner whose suggestion, direction, 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 CPT 99245 for the third-party Third-party mandated consultation.
Consultation Codes CPT 99241 – 99245
Consultation codes CPT 99241 – 99245 are used to represent second-opinion visits. Consultation is a sort of evaluation and management (E / M) service given by a physician at the request of a separate physician or other appropriate source. This is either to recommend treatment for a particular condition or problem or to determine whether they should be responsible for continuous patient treatment. It is not used as a code for E/M or related counseling.
Billing Examples
The following are examples of when CPT 99245 should be billed.
Example 1
An eighteen-year-old male with no medical history now presents severe pain in the right lower quadrant. The pain started seven days ago and got worse with movement. The patient did not take any medication for pain.
The patient denies headache, blurry vision, itching, dryness, dizziness, chest pain, shortness of breath, motor weakness, numbness/tingling, nausea/vomiting, and urinary bladder issues.
Physicians order diagnostic services such as CT and MRI of the abdomen and pelvis region. Diagnostic studies revealed that the patient has acute appendicitis. The patient’s condition is getting worse and has the possibility of appendix rupture or spreading infections to the other organs.
The physician consulted with Gastrentrologyst for further proceedings and suggested immediately removing the appendix from the body. He schedules an appointment for an appendectomy by tomorrow.
Example 2
A Thirty-year-old male with no medical history now presents with an acute abdominal injury. The patient had a road traffic accident today. He got bruises on the head, neck, and abdominal region.
The patient denies headache, blurry vision, itching, dryness, dizziness, chest pain, shortness of breath, motor weakness, numbness/tingling, nausea/vomiting, and urinary bladder issues.
Physicians order diagnostic services such as CT and MRI of the abdomen and pelvis region. Diagnostic studies revealed that the patient has acute appendicitis. The patient’s condition is getting worse and has the possibility of appendix rupture or spreading infections to the other organs.
The physician consulted with Gastrentrologyst for further proceedings and immediately suggested a Laparotomy of the abdominal region. He schedules an appointment for an appendectomy by tomorrow.
Example 3
A forty-six-year-old male with CKD 5 as a past medical history now presents with end-stage renal disease. The patient’s condition is getting worse with every moment. The primary care physician consulted with a Urologist.
The patient denies headache, blurry vision, itching, dryness, dizziness, chest pain, shortness of breath, motor weakness, numbness/tingling, nausea/vomiting, and urinary bladder issues.
Physicians order diagnostic services such as CT and MRI of the abdomen and pelvis region. Diagnostic studies revealed that the patient has acute appendicitis. The patient’s condition is getting worse and has the possibility of appendix rupture or spreading infections to the other organs.
The physician consulted with a urologist for further proceedings and suggested an immediate kidney transplant. He schedules an appointment for a kidney transplant by tomorrow.
Example 4
Initial office consultation for a 35-year-old multiple-trauma male patient with complex pelvic fractures for evaluation and management plan formulation. (Orthopaedic Surgery)
Example 5
Initial emergency room consultation for a 10-year-old male in status epilepticus, recent closed head injury; information about medication unavailable. (Neurosurgery)
Example 6
Initial emergency room consultation for a 23-year-old patient with severe abdominal pain, guarding, febrile, and unstable vital signs. (Obstetrics & Gynaecology)
Example 7
Office consultation for a 67-year-old female longstanding uncontrolled diabetic who presents with retinopathy, nephropathy, and a foot ulcer. (Endocrinology)
Example 8
Office consultation for a 37-year-old male for initial evaluation and management of Cushing’s disease. (Endocrinology)
Example 9
Office consultation for a 60-year-old male who presents with thyrotoxicosis, exophthalmos, frequent premature ventricular contractions, and congestive heart failure. (Endocrinology)
Example 10
Initial office consultation for a 60-year-old patient, one-year status post occupational herniated cervical disk treated by laminectomy, requiring management of multiple sites of intractable pain, depression, and narcotic dependence. (Pain Medicine)
Example 11
Office consultation for a 58-year-old man with a history of MI and CHF who complains of the recent onset of rest angina and shortness of breath; the patient has a systolic blood pressure of 90 mmHg and is in Class IV heart failure. (Cardiology)
Example 12
Emergency room consultation for a 1-year-old with a three-day history of fever with increasing respiratory distress who is thought to have cardiac tamponade by the ER physician. (Cardiology)
Example 13
Office consultation in the emergency room for a 25-year-old male with a severe, acute, closed head injury. (Neurosurgery)
Example 14
Office consultation in the emergency room for a 25-year-old male with a severe, acute, closed head injury. (Neurosurgery)
Example 15
Office consultation for a 23-year-old female with Stage II A Hodgkins disease with positive supraclavicular and mediastinal nodes. (Radiation Oncology)
Example 16
Office consultation for a 27-year-old juvenile diabetic patient with severe diabetic retinopathy, gastric atony, nephritic syndrome, and progressive renal failure, now with a serum creatinine of 2.7 and a blood pressure of 170/114. (Nephrology)
Example 17
Office consultation for independent medical evaluation of a patient with a history of complicated low back and neck problems with previous multiple failed back surgeries. (Orthopaedic Surgery)
Example 18
Office consultation for an adolescent referred by a pediatrician for recent onset of violent and dangerous behavior. (Psychiatry)
Example 19
Office consultation for a 6-year-old male for evaluation of severe muscle and joint pain and a diffuse rash, Patient well until 4-6 weeks earlier, when he developed arthralgia, myalgia, and a fever of 102 degrees for one week. (Rheumatology)
