cpt 99241, 99242 - Difference between

The CMS concurs with American Medical Association “Current Procedural Terminology (CPT)” guidelines related to physician reporting of inpatient and outpatient consultation services 99241-99243, 99244-99255:

CPT 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.

The CMS will pay a consultation fee when the service is provided by a physician at the request of the patient’s attending physician when:

• All of the criteria for the use of a consultation code are met;
• The consultation is followed by treatment;
• The consultation is requested by members of the same group practice;
• The documentation for consultations has been met (written request from an appropriate source and a written report furnished the requesting physician);
• Pre-operative consultation for a new or established patient performed by any physician at the request of the surgeon; and
• A surgeon requests that another physician participate in post-operative care (provided that the physician did not perform a pre-operative consultation).
Italicized and/or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 1999 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.


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:

In Summary

As with any other CPT coding issue, if you have any questions you may refer directly to your current copy of the AMA CPT book.

PF Problem Focused EPF Expanded Problem Focused D Detailed C Comprehensive SF Straightforward Complexity L Low Complexity
M Moderate Complexity H High Complexity


CPT Code 99241 99242 99243 99244 99245 99251 99252 99253 99254 99255 Minutes 15 30 40 60 80 20 40 55 80 110



Evaluation and Management Codes for A/B MAC (B) Edits

92012 92014 99211 99212 99213 99214 99215 99217 99218 99219 99220 99221 99222 99223 99231 99232 99233 99234 99235 99236 99238 99239 99241 99242 99243 99244 99245 99251 99252 99253 99254 99255 99261 99262 99263 99271 99272 99273 99274 99275 99291 99292 99301 99302 99303 99311 99312 99313 99315 99316 99331 99332 99333 99347 99348 99349 99350 99374 99375 99377 99378

NOTE: In order for codes 99291 or 99292 to be paid for services furnished during the preoperative or postoperative period, modifier “-25” or “-24,” respectively, must be used to indicate that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed.

If a surgeon is admitting a patient to a nursing facility for a condition not related to the global surgical procedure, the physician should bill for the nursing facility admission and care with a “-24” modifier and appropriate documentation. If a surgeon is admitting a patient to a nursing facility and the patient’s admission to that facility relates to the global surgical procedure, the nursing facility admission and any services related to the global surgical procedure are included in the global surgery fee.


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