This article will define CPT Code 99242, explain the medical necessity to report CPT 99242, and the guidelines and clinical examples of CPT 99242.
Be aware that CPT code 99242 has been revised on the 1st of January, 2023. This article is about the previous version of the code description.
Description Of CPT Code 99242
CPT Code 99242 is defined by the CPT manual as follows (the text in Italic is the official definition of CPT 99242):
Office consultation for a new or established patient which requires these three key components:
- Component 1: An expanded problem-focused history
- Component 2: An expanded problem-focused examination
- Component 3: A straightforward medical decision making
Counselling and/or coordination of care with other providers 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 low to moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family.
Consultation CPT Codes 99241 – 99245
Consultation CPT codes 99241 – 99245 are used to show second opinion visits. Consultation is a sort of evaluation and management (E / M) service provided by a doctor at the request of another doctor or other appropriate source, either to recommend treatment for a particular condition or problem or to determine whether they should be responsible for continuous treatment. It does not serve as a CPT code for E/M, or related counseling.
Evaluation & Management Consultation Codes
When to code an evaluation and management (E / M) service as a consultation is a commonly discussed query in determining if an E / M service is a consultation. The discreet variation between a consultation and an office visit is that the consultation is performed by a doctor whose knowledge or advice regarding E / M of a particular problem is sought from another doctor. A visit to the doctor is considered a consultation only if the following criteria are met for the use of a consultation code:
- The consultation is made at the request of another physician or an appropriate source seeking advice on E / M on a particular problem.
- The request for a consultation and the purpose of the request must be noted in the medical history record of the patient.
- Post-consultation, the doctor must prepare a written report sent to the referring doctor.
When the above requirements are not completed, the appropriate office or another outpatient (CPT codes 99201 – 99215) or hospital inpatient (CPT code 99221 – 99223) E / M service can be reported contrary to a consultation CPT code.
Below you can find billing examples of the 99242 CPT code.
Initial office consultation for a 20-year-old male with acute upper respiratory tract symptoms. (Allergy & Immunology)
Initial office consultation for a 29-year-old soccer player with a painful proximal thigh/groin injury. (Orthopaedic Surgery)
Initial office consultation for a 66-year-old female with wrist and hand pain, numb fingertips, and suspected median nerve compression by carpal tunnel syndrome. (Plastic Surgery)
Initial office consultation for a patient with a solitary lesion of discoid lupus erythmatosus on the left cheek to rule out malignancy or self-induced lesion. (Dermatology)
Office consultation for management of systolic hypertension in a 70-year-old male scheduled for elective prostate resection. (Geriatrics)
Office consultation with a 27-year-old female with an old amputation to evaluate existing above-knee prosthesis. (Physical Medicine & Rehabilitation)
Office consultation with a 66-year-old female with wrist and hand pain and finger numbness secondary to suspected carpal tunnel syndrome. (Orthopaedic Surgery)
Office consultation for a 61-year-old female, recently on antibiotic therapy, now with diarrhea and leukocytosis. (Abdominal Surgery)
Office consultation for a patient with papulosquamous eruption of the elbow with pitting of nails and itchy scalp. (Dermatology)
Office consultation for a 30-year-old female with single-season allergic rhinitis. (Allergy & Immunology)