99244

Office or Other Outpatient Consultation, Moderate Medical Decision Making or 45-59 Minutes

CPT code 99244 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 (MDM). Alternatively, if code selection is based on time, 45-59 minutes of total time must be spent on the date of the encounter. A consultation involves a physician or other qualified health care professional providing an expert opinion or advice regarding the evaluation and/or management of a specific problem at the request of another physician or appropriate source. The consulting physician thoroughly reviews the patient's medical history, performs a pertinent physical examination, and evaluates diagnostic test results to formulate an assessment and recommend a treatment plan. The moderate level of MDM typically involves reviewing a moderate amount of data, managing conditions with a moderate risk of morbidity/mortality, or dealing with multiple or complex acute/chronic illnesses. The service concludes with a written report to the requesting physician and, usually, the patient is then referred back to the requesting physician for ongoing care, although in some cases, the consultant may assume responsibility for management. This code reflects the cognitive work and time invested in assessing a patient's condition when a focused expert opinion is sought, particularly for complex diagnostic issues or challenging management scenarios.

Clinical Indications

  • Second opinion for complex or chronic conditions.
  • Evaluation of diagnostic dilemmas requiring specialized expertise.
  • Pre-surgical assessment by a specialist not performing the surgery.
  • Management recommendations for conditions outside the primary care physician's specialty.
  • Review of treatment failures or unsatisfactory responses to therapy.
  • Assessment for eligibility for specialized programs or clinical trials.
  • Determination of prognosis or functional capacity for complex medical issues.
  • Patients with multiple comorbidities requiring integrated care planning.
  • Evaluation of unusual or rare diseases.
  • Recommendations for advanced diagnostic testing or therapeutic interventions.

Procedure Steps

  1. Receive a formal request for a consultation from another physician or appropriate source, specifying the reason for the consultation.
  2. Obtain a comprehensive medical history relevant to the presenting problem, including past medical history, family history, social history, review of systems, and current medications.
  3. Perform a medically appropriate physical examination focused on the organ systems relevant to the consultation request.
  4. Thoroughly review existing medical records, diagnostic test results (e.g., labs, imaging, pathology reports), and previous treatment attempts.
  5. Synthesize all gathered information, analyze the complexity of the problem, consider differential diagnoses, and formulate an assessment and a comprehensive treatment plan or recommendation.
  6. Discuss findings, potential diagnoses, prognosis, and recommended treatment options with the patient and/or family, addressing their concerns.
  7. Document the complete history, examination findings, review of data, assessment, plan, and the total time spent (if using time for code selection) in the patient's medical record.
  8. Generate a written report detailing the findings, assessment, and recommendations, and communicate this to the requesting physician.
  9. Typically, refer the patient back to the requesting physician for ongoing management based on the consultant's recommendations, or in some instances, assume ongoing care for the specific problem.

Coding Guidelines

  • **Definition**: CPT code 99244 is an office or other outpatient consultation requiring a medically appropriate history and/or examination and moderate level of medical decision making, or 45-59 minutes of total time on the date of the encounter.
  • **Payer Specifics**: While valid CPT codes, Medicare Part B no longer recognizes codes 99241-99245 for consultation services. For Medicare patients, services that would traditionally be coded as consultations are typically reported using new or established patient office/outpatient E/M codes (99202-99215) depending on the patient's status and the level of service provided. Many commercial payers, however, may still recognize and pay for CPT consultation codes. Always verify payer-specific policies.
  • **Medical Decision Making (MDM)**: A moderate level of MDM involves meeting at least two of the three MDM elements: (1) Multiple stable chronic illnesses, or one or more acute complicated illnesses, or one undiagnosed new problem with uncertain prognosis, or one acute illness with systemic symptoms, or one acute complicated injury. (2) Moderate amount and/or complexity of data to be reviewed and analyzed (e.g., review of prior external note(s) from each unique source, review of results of each unique test, ordering of each unique test, assessment requiring an independent historian, interpreter, or information from other sources, discussion of management options with external physician/QHP, independent interpretation of imaging/tracings, discussion of case with patient/family not counted as MDM for data). (3) Moderate risk of complications and/or morbidity or mortality of patient management (e.g., prescription drug management, decision regarding minor surgery with identified risk factors, decision regarding elective major surgery without identified risk factors, diagnosis or treatment significantly limited by social determinants of health).
  • **Time-Based Coding**: If counseling and/or coordination of care dominates more than 50% of the encounter, or if the practitioner chooses to report based on time, 45-59 minutes of total time must be documented. Total time includes both face-to-face and non-face-to-face time spent by the physician or other qualified health care professional on the date of the encounter, including preparation, history, exam, counseling, ordering, referring, and documenting.
  • **Documentation**: Thorough documentation is paramount, including the request for consultation, the reason, the findings, the opinion, and the recommendations provided to the requesting physician. The patient's status (new or established) also influences code selection if using office/outpatient E/M codes instead of consultation codes.
  • **Distinction from Referral**: A consultation implies the consultant's opinion is requested, and the patient generally returns to the referring physician. A referral implies the complete transfer of care for the specific problem to the specialist.

Associated ICD-10 Codes