CPT 99243, cpt code 99243, 99243 cpt code

CPT 99243 | Office/Other Outpatient Consultation | Low-Level | 30 Minutes Or More

CPT code 99243 describes an office or outpatient consultation service that includes a medically appropriate history and/or examination, low-level medical decision-making, and at least 30 minutes of total time spent on the encounter on the service date for a new or established patient.

What Is CPT Code 99243?

CPT code 99243 can be used to report an office or outpatient consultation service provided to a new or established patient.

The service includes a medically appropriate history and/or examination and a low level of medical decision-making. The total time spent on the encounter on the service date must be at least 30 minutes.

The term “medically appropriate history and/or examination” means that the provider will take a detailed history of the patient’s symptoms, medical history, and other relevant information.

The provider will also perform a physical examination if necessary. The provider will use this information to determine the nature and extent of the patient’s condition and to determine the best course of treatment or further diagnostic testing.

The “low level of medical decision-making” means that the provider will use minimal data and analysis to determine the diagnosis and treatment plan. This could include a straightforward diagnosis with a clear-cut treatment plan or a minor problem with a predictable outcome.

Description

The CPT book describes CPT code 99243 as: “Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.”

Procedure

The provider conducts an evaluation and management (E/M) consultation for a patient in an office or outpatient setting.

The consultation includes a low level of medical decision-making or at least 30 minutes of total time spent on the encounter on a single date. The total time includes face-to-face and non-face-to-face activities on the encounter date.

The E/M service may include taking a patient history and performing a physical examination, as deemed appropriate by the provider.

The provider will evaluate the patient’s symptoms and medical history and will determine the best course of treatment or further diagnostic testing that may be necessary.

The level of medical decision-making (MDM) is essential in determining the service level provided.

Elements of MDM include:

  • The number and complexity of problems addressed.
  • The risk of complications, morbidity, and mortality related to patient management.
  • The amount and/or complexity of data to review and analyze.

A qualified healthcare professional, social worker, or insurance company must request the consult.

The consulting provider must communicate with the requesting source to share the provider’s opinion and information on services rendered. This communication is vital in ensuring continuity of care and proper coordination between healthcare providers and agencies.

The provider must also document the encounter in the patient’s medical record and may order any necessary diagnostic tests or refer the patient to a specialist.

How To Use CPT 99243

CPT code 99243 can be used if a provider conducts a medically appropriate history and/or physical examination. The provider should also document all services performed during the procedure in the patient’s medical record.

CPT 99252, CPT 99253, CPT 99254, and CPT 99255 can be used for observation or inpatient consultations.

You should check with the payer for coverage and use policies of these codes before billing. The appropriate E/M service level should be chosen based on the total time or medical decision-making level stated in the code descriptor of CPT 99243.

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