How To Use CPT Code 99243

CPT 99243 is an office or outpatient consultation code for new or established patients, involving a medically appropriate history and/or examination and low level of medical decision making. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 99243.

1. What is CPT 99243?

CPT 99243 is a code used by medical professionals to bill for office or outpatient consultation services provided to new or established patients. These consultations involve a medically appropriate history and/or examination and a low level of medical decision making. The code is used to accurately document and bill for the services provided during the consultation, ensuring proper reimbursement for the healthcare provider.

2. 99243 CPT code description

The official description of CPT code 99243 is: “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.”

3. Procedure

The 99243 CPT code procedure involves the following steps:

1. Reviewing the patient’s medical history and/or conducting a physical examination as deemed medically appropriate by the provider.
2. Evaluating the patient’s condition and determining the level of medical decision making required.
3. Spending at least 30 minutes on the encounter, including both face-to-face and non-face-to-face activities.
4. Documenting the encounter, including the history, examination, and medical decision making.
5. Communicating the provider’s opinion and information on services rendered to the requesting source.

4. Qualifying circumstances

Patients eligible to receive CPT code 99243 services include new or established patients who require an office or outpatient consultation involving a medically appropriate history and/or examination and a low level of medical decision making. The consultation must be requested by an appropriate source, such as a qualified healthcare professional, social worker, or insurance company. The provider must also communicate their opinion and information on services rendered to the requesting source.

5. When to use CPT code 99243

It is appropriate to bill the 99243 CPT code when the provider has performed an office or outpatient consultation for a new or established patient, involving a medically appropriate history and/or examination and a low level of medical decision making. Additionally, the total time spent on the encounter must be at least 30 minutes, including both face-to-face and non-face-to-face activities.

6. Documentation requirements

To support a claim for CPT 99243, the following information must be documented:

• Medically appropriate history and/or examination performed by the provider.
• Low level of medical decision making involved in the encounter.
• Total time spent on the encounter, including both face-to-face and non-face-to-face activities, meeting or exceeding 30 minutes.
• Request for consultation from an appropriate source.
• Communication of the provider’s opinion and information on services rendered to the requesting source.

7. Billing guidelines

When billing for CPT code 99243, it is important to follow these guidelines:

• Ensure that the service provided meets the criteria for CPT 99243, including a medically appropriate history and/or examination, low level of medical decision making, and at least 30 minutes of total time spent on the encounter.
• Document all required information to support the claim, as outlined in the documentation requirements section.
• Verify payer policy regarding the use and coverage of CPT 99243, as some payers may have specific rules or restrictions.

8. Historical information

CPT 99243 was added to the Current Procedural Terminology system on January 1, 1992. Since then, there have been several updates to the code description, with the most recent change occurring on January 1, 2023.

9. Similar codes to CPT 99243

Five similar codes to CPT 99243 include:

• CPT 99241: Office or outpatient consultation with a problem-focused history and/or examination and straightforward medical decision making.
• CPT 99242: Office or outpatient consultation with an expanded problem-focused history and/or examination and straightforward medical decision making.
• CPT 99244: Office or outpatient consultation with a comprehensive history and/or examination and moderate level of medical decision making.
• CPT 99245: Office or outpatient consultation with a comprehensive history and/or examination and high level of medical decision making.
• CPT 99251: Inpatient consultation with a problem-focused history and/or examination and straightforward medical decision making.

10. Examples

Here are 10 detailed examples of CPT code 99243 procedures:

1. A patient with a history of hypertension is referred by their primary care physician for a consultation with a cardiologist to evaluate the need for medication adjustments.
2. An oncologist is consulted to provide a second opinion on a patient’s cancer treatment plan, including a review of the patient’s medical history and examination findings.
3. A patient with chronic pain is referred to a pain management specialist for a consultation to discuss alternative treatment options.
4. A pediatrician consults with a child psychologist to evaluate a child’s behavioral issues and determine if further intervention is needed.
5. A patient with a history of gastrointestinal issues is referred to a gastroenterologist for a consultation to discuss potential diagnostic tests and treatment options.
6. An orthopedic surgeon is consulted to evaluate a patient’s knee pain and determine if surgical intervention is necessary.
7. A patient with a history of migraines is referred to a neurologist for a consultation to discuss potential triggers and treatment options.
8. A dermatologist is consulted to evaluate a patient’s skin condition and determine if further testing or treatment is needed.
9. A patient with a history of diabetes is referred to an endocrinologist for a consultation to discuss potential medication adjustments and lifestyle modifications.
10. A rheumatologist is consulted to evaluate a patient’s joint pain and determine if further testing or treatment is necessary.