CPT Code 99243: Appropriate Use
CPT Code 99243 Description
Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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 moderate severity. Typically, 40 minutes are spent face-to-face with the patient and/or family. Before using CPT Code 99243 let’s understand what are consultation codes.
Consultation Codes 99241- 99245
Consultation codes i.e. CPT code 99243, 99241,…., 99245 are used to represent second-opinion visits. Consultation is a type of evaluation and management service provided by a physician at the request of another physician or other appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem. It is not used as a code for evaluation and management, nor the counseling associated with it.
|Code||Description||2020 wRVU||National Non-facility Payment||National Facility Payment|
|99241||Office consult – Level 1||0.64||$ 48.72||$ 33.56|
|99242||Office consult – Level 2||1.34||$ 92.03||$ 70.74|
|99243||Office consult – Level 3||1.88||$ 125.95||$ 98.89|
|99244||Office consult – Level 4||3.02||$ 188.75||$ 159.16|
|99245||Office consult – Level 5||3.77||$ 229.89||$ 196.69|
Non-Payment of Consultation Codes
- In 2010, Medicare stopped recognizing consultation codes. Medicare stated that they still did pay for consultations, but they used other codes to pay for them such as office visits, emergency department visits, and initial hospital services.
- Effective from Oct. 1, 2017, United Healthcare will no longer reimburse consultation services represented by CPT codes 99241-99245 and 99251-99255. United Healthcare will reimburse the appropriate evaluation and management (E/M) procedure code which describes the office visit, hospital care codes reported in lieu of a consultation services procedure code.
- Cigna is the latest payor to announce that it will no longer reimburse consultation services, effective for claims processed on or after October 19, 2019. Consultation services previously represented by CPT codes 99241-99245 and 99251-99255 will need to be billed utilizing the appropriate evaluation and management (E/M) procedure code that describes the office visit, hospital care, nursing facility care, home service or domiciliary/rest home care.
Evaluation and Management Consultation Codes
When to code an evaluation and management service as a consultation is one of the most frequently asked questions is how to determine if an evaluation and management (E/M) service is a consultation. The discreet difference between a consultation and an office visit is that a consultation is provided by a practitioner whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another practitioner. An office visit is deemed a consultation only when the following criteria for the use of a consultation code are met:
- Consultation is being performed at the ‘request’ of another practitioner or appropriate source requesting advice regarding evaluation and/or management of a specific problem.
- The request for the consultation and the reason for the request must be ‘recorded’ in the patient’s medical record.
- After the consultation is provided, the practitioner must prepare a written report of his or her findings, which is provided to the referring practitioner.
If all the listed requirements are not met then the appropriate office or other outpatient (99201-99215) or hospital inpatient (99221-99223) E/M service should be reported instead of a consultation code.
Consultation vs Referral
Some of the confusion in coding consultations begins with the terms used to describe the requested service. The word ‘consultation’ and the word ‘referral’ are sometimes incorrectly considered one and the same. When a practitioner refers a patient to another practitioner, it cannot be automatically considered a consultation. The service can only be considered a consultation if the above criteria are met in the service provided. A service provided to a patient who was referred to another practitioner without written or verbal request for a consultation (which is documented in the patient’s record) should be coded using one of the office or other outpatient codes or hospital care codes.
The decision to request a consultation is exclusively up to the requesting practitioner. The medical necessity for a consultation is dependent on the clinical judgment of the practitioner. Once the requesting practitioner receives the report from the consulting practitioner, he or she may either continue to manage the patient’s condition or request the consulting practitioner to take over the management of the patient’s condition from that point forward. If the consulting practitioner chooses to accept management of the patient’s condition after the consultation has been completed, the appropriate code from the office or other outpatient or hospital inpatient should be used for any further E/M services provided.
- A consult requires a request from another health care professional for a new or established problem for your evaluation, assessment or opinion
- After service is provided, a report is returned to the requesting clinician
- Document request in the medical record
- Transfer of care is not a consult
- Office consults are not defined as new or established
Guidelines for Billing with Consultation Codes
Here are some guidelines to help you decide if you qualify for use of a consultation code 99241-99245. Documentation must include evidence of the following:
- A third-party-mandated consultation
- Documentation of a request for a consultation from an appropriate source
- Documentation of the need for consultation in the patient’s medical record
- One consultation per consultant
- Provision by a physician or qualified nonphysician practitioner whose advice, opinion, recommendation, suggestion, direction or counsel is requested for evaluation and treatment
- recommendations of a patient, since that individual’s expertise in a specific medical area is beyond the scope of knowledge of the requesting physician or qualified nonphysician practitioner
- Provision of a written report of findings/recommendations from the consultant to the referring physician or qualified nonphysician practitioner
- Consultation codes should not be billed repeatedly or when the consultation is prompted by the patient/family.
CPT © Copyright 2021 American Medical Association
Hope this article gives you a good understanding of CPT code 99243. For accurate medical billing, knowing your CPT codes is the most important thing. In our blog series of ‘Know Your Codes’ or ‘KYC,’ we have discussed the most common CPT codes in detail and when to use them. E2E Medical Billing Services is known for its accurate and affordable medical billing services. To know more about our medical billing services call us at 888-552-1290 or write to us at [email protected]