CPT code 99244 , 99245 comparison usage

CPT CODE and Description

99244 - Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate 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 to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family - Average payment - $170 - $200


99245 - Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high 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 to high severity. Typically, 80 minutes are spent face-to-face with the patient and/or family. Average payment - $210 - $250

Office Consultation Codes 99244 and 99245

Procedure Codes 99244 and 99245 require the following key components:



Level IV – 99244 Level V – 99245
History – Comprehensive

Exam – Comprehensive

MDM – Moderate Complexity
History – Comprehensive

Exam – Comprehensive

MDM – High Complexity

As a result of these review findings, a prepayment edit will be implemented on procedure code 99245.


Medical records will be requested to verify that services billed were rendered, medically necessary and billed appropriately to the Medicare program.  If the requested medical record documentation is not made available to support services billed, the service may be denied.


Contractors pay for reasonable and medically necessary consultation services when all of the following criteria are met:


  • A consultation service is distinguished from other evaluation and management (E/M) visits because it is provided by a physician or qualified non-physician practitioner (NPP) whose opinion or advice regarding evaluation and management of a specific problem is requested by another physician or other appropriate source; and

  • A request for consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) should be documented by the consultant in the patient’s medical record; and

  • After the consultation is provided, the consultant should prepare a written report of his/her findings and recommendations, which must be provided to the referring physician. 
For additional information regarding the indications and limitations as well as the documentation requirements for consultation services please refer to Local Coverage Determination, L27484 “Consultations”, located on our website.

Highmark Medicare Services is dedicated to providing education and assisting providers in understanding Medicare regulations.   Education on E/M services is provided through many convenient channels including workshops, training modules, and our E/M Center located on our website. 

 The E/M center can be found on the Part B Homepage.  To access this site, click on the “E/M Center” link located on the left-hand side of the page.  Please refer to this center in order to access the most current information and educational materials regarding E/M services.


Which Level to Choose

Once you have determined that the visit meets all the criteria to be considered a consult, the next issue is which level to choose. To select the appropriate level consultation code, all three key components (history, examination and medical decision-making) must meet or exceed the requirements stated in CPT®
to qualify for a specific level of E/M service. Refer to the following table:




Consult code which level to use 99241 - 99245


Choosing the level using Time as the deciding factor

When is it appropriate to choose the level of E/M Consultation based on time? You may choose the level based on time when you have spent greater than 50% of the total time of the visit in counseling or coordination of care for your patient. The guidelines are very clear as to the proper way to document this occurrence. Your note must show the following:

1. Total time of the visit must be documented.

2. The content of the counseling and/or coordination of care must be documented.

3. The note must clearly state that greater than 50% of the total time was spent in counseling and/or coordination of care.

An example of this documentation is as follows: Total visit 30 minutes, 20 minutes spent counseling patient on side ef ects of medication (99242). The times for each level are listed in the table below:

CPT Code Minute

99241     15 Min
99242     30 Min
99243     40  Min
99244  60 Min

99245  80 Min


Evaluation and Management CONSULTATIONS (Codes 99241-99245)

When to Code an Evaluation and Management Service as a Consultation

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:

1. Consultation is being performed at the REQUEST of another practitioner or appropriate source requesting advice regarding evaluation and/or management of a specific problem 

2. The request for the consultation and the reason for the request must be RECORDED in the patient’s medical record.

3. 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.

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. 



Examples That Do Not Fulfill the Criteria for Consultations:

Standing orders in the medical record for consultations

No order for a consultation

No written report of a consultation


Consults

If a column has 3 circles, draw a line down the column and circle the code OR find the column with the circle farthest to the left, draw a line down the column and circle the code





Consultation and office visit CPT cross walk


CPT Consultation Code Coding Crosswalk New Patient (Requires all three key components) CPT Crosswalk Established Patient (Requires two of three key components)

CPT 99244 As 99204
• A comprehensive history
• A comprehensive examination
• Medical decision making of moderate complexity

As 99214
• A comprehensive history
• A comprehensive examination
• Medical decision making of moderate complexity


CPT 99245 AS 99205
• A comprehensive history
• A comprehensive examination
• Medical decision making of high complexity

AS 99215
• A comprehensive history
• A comprehensive examination
• Medical decision making of high complexity


Billing Bundling Guidelines

99244 to 99214
99245 to 99215

Office Visits - Office services provided on an emergency basis (99058) are considered mutually exclusive to the primary services provided.

Office visit (99211) is considered mutually exclusive to 95115-95117(allergen immunotherapy). Separate reimbursement is not allowed for mutually exclusive services.

Pap Smears - Obtaining a pap smear is integral to the office visit. This includes both preventive and routine office visits. Separate reimbursement is not allowed for Q0091.

Pathologists - Claims submitted by pathologists (provider specialty 29) for clinical interpretation of laboratory results will be allowed for codes 83020, 84165, 84166, 84181, 84182, 85060, 85390, 85576, 86255, 86256, 86320, 86325, 86327, 86334, 86335, 87164, and 87207. Pathology interpretation of all other codes in the 80002-87999 range is considered integral to the laboratory test. Separate reimbursement is not allowed for integral services.

Pulse Oximetry - Pulse oximeters are considered incidental to office visits or procedures. Separate reimbursement is not provided for incidental procedures.

Respiratory Treatments - Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB devise is considered mutually exclusive to an office visit.

Separate reimbursement is not provided for mutually exclusive services.

Robotic Surgical Systems - Payment for new technology is based on the outcome of the treatment rather than the “technology” involved in the procedure. Additional reimbursement is not provided for the robotic surgical technique.

STAT or After Hours Laboratory Charges - Additional charges for STAT or after hours laboratory services are considered an integral part of the laboratory charge.

Surgical Supplies - Surgical supplies will be considered incidental to Surgical; Laboratory; Inpatient, Outpatient or Office Medical Evaluation and Management; and Consultation services.

Surgical dressings applied in the provider’s office are considered incidental to the professional services of the health care practitioner and are not separately payable. Surgical dressings billed in the provider’s office (place of service 11) will be denied.

Surgical trays and miscellaneous medical and/or surgical supplies are generally considered incidental to all medical, chemotherapy, surgery, and radiology services, including those performed in the office setting.

Supplies (except those related to splinting and casting) are considered components of the 0, 10, and 90- day global surgical package, and are not separately billable on the same date of service as the 0, 10, or 90-day procedure.

Supplies are not covered when they do not require a prescription and can be purchased by the member over-the-counter or when they are given to the member as take-home supplies. Medical and/or surgical supplies, such as dressings and packings, used during the course of an office visit are generally considered incidental to the office visit.

Compression/pressure garments, elastic stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are examples of items that are not ordinarily covered.

Transvaginal Ultrasound - Transvaginal ultrasound (76830) is considered mutually exclusive to a  hysterosonography with or without color flow Doppler (76831).

Venipuncture - Refer to policy “Code Bundling Rules Not Addressed in Claim Check.”

Vision Services - please refer to CEC's bundling guidelines related to routine vision services.


X-Rays - When single view and double view chest X-Rays are billed together (71010 and 71020), only the double view X-Ray is allowed. When the entire spine, survey study is billed (72082) with cervical spine films (72040), thoracic spine films (72070) or lumbosacral spine films (72100) only the entire spine, survey study code is allowed. When a single view X-Ray code is billed with a multiple view X-Ray code, only the multiple view X-Ray code is allowed (e.g., 72020 with 72040, 72070, or 72100). Only one professional and one technical component are allowable per X-Ray 


Indications

The intent of a consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge. Consultations may be billed based on time if the counseling/coordination of care constitutes more than 50 percent of the face-to-face encounter between the physician or qualified NPP and the patient. The preceding requirements (request, evaluation (or counseling/coordination) and written report) must also be met when the consultation is based on time for counseling/coordination.

A consultation may not be performed as a split/shared E/M visit.


Consultation Followed By Treatment

A physician or qualified NPP consultant may initiate diagnostic services and treatment at the initial consultation service or subsequent visit. Ongoing management, following the initial consultation service by the consultant physician, should not be reported with consultation service codes. These services should be reported as subsequent visits for the appropriate place of service and level of service. Payment for a consultation service should be made regardless of treatment initiation unless a transfer of care occurs.


Transfer of Care

A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patients’ complete care for the condition and does not expect to continue treating or caring for the patient for that condition.

When this transfer is arranged, the requesting physician or qualified NPP is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for the condition. The receiving physician or qualified NPP shall document this transfer of the patient’s care to his/her service in the patient’s medical record or plan of care.


In a transfer of care the receiving physician or qualified NPP would report the appropriate new or established patient visit code according to the place of service and level of service performed and should not report a consultation service.


Initial Consultation Service

Office or other outpatient setting

In the office or other outpatient setting, the consulting physician or qualified NPP should use the appropriate Office or Other Outpatient Consultation (new or established patient) codes (99241 – 99245) for the initial consultation service as described: CPT code 99241 – office consultation for a new or established patient, which requires these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers 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 self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family. CPT code 99242 – office consultation for a new or established patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers 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 self limited or minor. Physicians typically spend 30 minutes face-to-face with the patient and/or family. CPT code 99243 – office consultation for a new or established patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers 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 self limited or minor. Physicians typically spend 40 minutes face-to-face with the patient and/or family. CPT code 99244 – office consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers 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 self limited or minor. Physicians typically spend 60 minutes face-to-face with the patient and/or family. CPT code 99245 – office consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other providers 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 self limited or minor. Physicians typically spend 80 minutes face-to-face with the patient and/or family.

If an additional request for an opinion or advice, regarding the same or a new problem with the same patient, is received from the same or another physician or qualified NPP and documented in the medical record, the Office or Other Outpatient Consultation (new or established patient) codes (99241 – 99245) may be used again. However, if the consultant continues to care for the patient for the original condition following his/her initial consultation, repeat consultation services should not be reported by this physician or qualified NPP during his/her ongoing management of this condition.

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