99245 CPT code

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. 

99245 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. 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.

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. 

cpt 99245

The following are essential components when CPT 99245 bills:

Typically requires 80 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 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 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 code 99245

99245 CPT Code 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 6.88813when 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.

99245 cpt code description

99245 CPT Code Modifiers

The following is the list of modifiers when CPT 99245 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 99245 CPT code are 24, 25, and 95.

Modifier 25 will be appended with CPT 99245 when services perform in conjunction with other services not customarily billed together on the same day. 

Modifier 24 appends with CPT 99245 when service performs in the post-operative period with unrelated procedures or services.

Modifier 95 will be attached to 99245 CPT code if the service provides during a telehealth visit.

Modifier 57 will be attached to CPT 99245 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 99245 must apply the GA modifier to that service.

99245 CPT Code 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 10 plus systems as per 95 documentation and 8 plus systems with 4 bullets required 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, 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 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 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 figure out whether they should be responsible for continuous treatment of the patient. It is not used as a code for E / M, or the related counselling aspect.

99245 CPT Code Examples

The following are the examples when CPT 99245 bills:

Example 1

An eighteen-year-old male with no past medical history now presents with severe pain in the right lower quadrant. The pain was 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 past 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 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 Urologistt 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 formulation of management plan. (Orthopaedic Surgery)

Example 5

Initial emergency room consultation for 10-year-old male in status epilepticus, recent closed head injury, information about medication not available. (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 though to have cardiac tamponade by the ER physician. (Cardiology)

Example 13

Office consultation in the emergency room for a 25-year-old male with severe, acute, closed head injury. (Neurosurgery)

Example 14

Office consultation in the emergency room for a 25-year-old male with 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)

99245 CPT Code 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)

99245 CPT Code Example 18

Office consultation for an adolescent referred by pediatrician for resent onset of violent and injurious behaviour. (Psychiatry)

99245 CPT Code 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)

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