99499 CPT Code (2023) | Description, Guidelines, Reimbursement, Modifiers & Examples
99499 CPT code reports for service when the physician or other qualified healthcare professional performs unlisted office and other outpatients, hospital, consultation, evaluation, and management (E/M) services to new or established patients. It does not include all three components of evaluation and management settings but meets the medical necessity of the service rendered by the physician.
99499 CPT Code | Description
The physician sees the patient upon the request of the primary care provider regarding diagnosis and treatment or determination of the patient’s medical condition but does not meet the criteria of the lower-level code.
The most basic service, 99202 – 99499 CPT code, describes a problem-focused history and exam with straightforward medical decision-making encompassing approximately 15 minutes of face-to-face time if office or out patient visits 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 99202 – 99499 CPT code, respectively. Medical decision-making for 99202 – 99499 is the same as a level one visit (straightforward) and assigns low complexity for the level three service (99202 – 99499 CPT code).
At these service levels, the encounter can involve the face-to-face time of 30 (99202-99499) to 40 (99202-99499) 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 (99202 – 99499). 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 (99202 – CPT code 99499) involves MDM of high complexity and approximately 80 minutes of face-to-face time.
99499 CPT code reports for service when the physician or other qualified healthcare professional performs unlisted office and other outpatients, hospital, consultation, evaluation, and management (E/M) services to new or established patients.
Services may or may not be 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 99499 CPT code bills:
Typically requires 15 minutes of total time spent by the physician face-to-face with the patient or patient’s family if a lower-level code is selected. 99499 CPT code does not meet the lower level criteria but meets the medical necessity of service.
- 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.
99499 CPT Code | Reimbursement
A maximum of zero units can be a bill on the same service date of 99499 CPT code. In contrast, the three units allow when documentation supports the medical necessity of the service.
The cost and RUVS of CPT code 99499 are $0 and 0 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 99499 are $0 and 0 when performed in the non-facility.
The reimbursement is based on the procedure’s complexity but does not specify by the CMS.
The performing provider may report telemedicine services by adding modifier 95 to the 99499 CPT code. Services at the origination site report with HCPCS Level II code Q3014.
99499 CPT Code | Modifiers
The following is the list of modifiers when 99499 CPT code bills:
The most frequent modifiers used with CPT code 99499 are 24, 25, and 95.
Modifier 25 will be appended with CPT 99499 when services perform in conjunction with other services not customarily billed together on the same day.
Modifier 24 appends with CPT code 99499 when service performs in the post-operative period with unrelated procedures or services.
Modifier 95 will be attached to 99499 CPT code if the service provides during a telehealth visit.
Modifier 57 will be attached to CPT 99499 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 99499 must apply the GA modifier to that service.
99499 CPT Code | Billing Guidelines
Documentation should support the medical necessity of service. It reflects that service is medically necessary and appropriate.
99499 CPT code may or may not require 3 out of 3 components which are as follows:
A problem-focused history: It requires at least 1 HPI element, 1 ROS system, and two history components are needed 2 out of 3 parts (PFSH), but it does not meet the criteria for lowest level code.
A problem-focused examination requires one system per 95 documentation and one with no bullets required as per 97 documentation, but it does not meet the criteria for the lowest level code.
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, but it does not meet the criteria for lowest level code.
If time is mentioned in the medical notes, it is appropriate to bill based on time instead of MDM, which typically requires 15 minutes spent by the physician but does not meet the criteria for the lowest level code.
CPT code 99499 does not accept by Medicare. It is appropriate to the bill with HCPCS Level II G codes.
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 99499 includes the following services:
- Documentation for consultation requests 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 code 99499 for the third-party mandated consultation.
Examples
The following are the examples when CPT code 99499 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. The patient presents to ED for this problem, but it is not required an ED visit but needs medical intention.
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. The patient presents to ED for this problem, but it is not required an ED visit but needs medical intention.
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. The patient presents to ED for this problem, but it is not required an ED visit but needs medical intention.
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. The patient presents to ED for this problem, but it is not required an ED visit but needs medical intention.
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. The patient presents to ED for this problem, but it is not required an ED visit but needs medical intention.
