99243
Office or other outpatient consultation for a new or established patient, moderate level of medical decision making
The Current Procedural Terminology (CPT®) code 99243 represents an office or other outpatient consultation for a new or established patient. This service requires a medically appropriate history and/or examination and a moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30-44 minutes must be spent. A consultation involves a physician or other qualified health care professional providing an expert opinion and/or advice regarding the evaluation and/or management of a specific problem or condition, as requested by another physician or appropriate source. The consultant's findings and recommendations must be communicated to the requesting physician or source.
Clinical Indications
- Referral from another physician for a new or established patient with an undiagnosed or worsening complex medical problem requiring a specialist's opinion.
- Evaluation of a patient presenting with multiple chronic conditions that are poorly controlled or require adjustment of complex management strategies.
- Consultation for a patient with an acute exacerbation of a chronic illness where the etiology is unclear or standard treatments have been ineffective.
- Request for a second opinion regarding diagnostic uncertainty or complex treatment options for a patient with a moderate risk of morbidity/mortality.
- Assessment of a patient with a significant change in clinical status or new symptoms that are potentially related to a known condition but require expert interpretation.
Procedure Steps
- Receive and review the official request for consultation from the referring physician or appropriate source.
- Obtain a medically appropriate history, which may include a detailed history of present illness, review of systems, and pertinent past medical, family, and social history.
- Perform a medically appropriate examination focused on the presenting problem and relevant organ systems.
- Engage in moderate medical decision making, which typically involves evaluating a moderate number of diagnoses or management options, analyzing a moderate amount or complexity of data (e.g., review of prior tests, imaging, or external records), and assessing a moderate risk of morbidity or mortality from the patient's condition and/or treatment.
- Formulate diagnostic impressions and develop a comprehensive treatment plan or management recommendations.
- Document findings, recommendations, and communication with the referring physician or appropriate source in the patient's medical record.
- Order and review additional diagnostic tests, imaging, or refer to other specialists as indicated by the clinical picture.
Coding Guidelines
- CPT® consultation codes (99241-99245) are typically used when a referring physician or other appropriate source requests an expert opinion on a specific problem and the consulting physician provides a report back to the requester.
- For Medicare beneficiaries, consultation codes (99241-99245) are generally not recognized for reimbursement in the outpatient setting. Instead, use an appropriate office or other outpatient E/M code (99202-99215) for the service rendered.
- Private payers may still recognize and reimburse for consultation codes; always verify payer-specific policies.
- Code selection for 99243 is based on either meeting or exceeding the requirements for a moderate level of Medical Decision Making (MDM) or by documenting a total time of 30-44 minutes spent on the date of the encounter.
- The consulting physician must document the request for the consultation, their findings, the services rendered, the diagnosis, and their recommendations in the patient's medical record.
- If the consulting physician assumes responsibility for the ongoing management of the patient's problem after the initial consultation, subsequent visits should be coded using appropriate established patient E/M codes (e.g., 99213-99215).