CPT Code 99242: Office or Outpatient Consultation for a New or Established Patient

What is CPT code 99242?

CPT code 99242 is an evaluation and management (E/M) code for office or other outpatient consultations provided to a new or established patient. It involves a straightforward medical decision-making level or requires a total of at least 20 minutes on the encounter date.

Typically used by physicians or other qualified health care professionals, 99242 applies when another provider requests professional advice or opinion on a patient’s specific health issue of low to moderate severity. This consultation includes reviewing a medically appropriate history, conducting an expanded problem-focused examination, and providing recommendations back to the referring provider.

What is a level 2 office consultation?

A level 2 office consultation (99242 CPT code) entails assessing a patient's clinical condition that is of low to moderate severity and requires a basic level of medical decision making.

Typically, it involves taking an expanded problem-focused history, performing a limited examination relevant to the issue, and providing medical advice or recommendations to the referring provider. Commonly managed conditions may include mild infections, minor injuries, or stable chronic issues.

CPT code 99242 documentation requirements

Documentation supporting CPT code 99242 must clearly include:

Referring provider's request

Document the name of the referring provider and clearly state the reason for the consultation request.

Expanded problem-focused history

Include a medically relevant, and detailed history covering essential details directly related to the patient’s complaint.

Appropriate examination

Perform an expanded problem-focused examination related to the patient's presenting issues. A comprehensive examination or comprehensive history is typically unnecessary at this level.

Straightforward medical decision-making

Clearly document your evaluation and management decisions, clinical reasoning, and medical recommendations based on a straightforward medical decision-making level.

Consultation report

Prepare and send a documented summary of your findings and recommendations back to the referring provider.

Time documentation (if time-based)

Include total face-to-face time, especially if billing based on time spent (20–29 minutes).

CPT code 99242 billing guidelines

Adhere to these billing guidelines when reporting the 99242 CPT code:

Required provider request

Bill only when a formal request for consultation has been made by another healthcare professional. This is not appropriate for self-referrals or routine care visits.

No treatment-only referrals

Cannot be billed if the referral was made strictly for transferring care or initiating treatment rather than seeking professional advice or opinion.

Documentation of return communication

Must document that a written report was sent back to the requesting healthcare provider detailing your consultation findings and recommendations.

Time criteria

When billing based on time, use 99242 for encounters lasting 20–29 minutes total on the day of service.

Verify payer acceptance

Confirm acceptance of consultation codes by payers, as some insurance providers (including Medicare) no longer reimburse other outpatient consultation codes.

Applicable modifiers for CPT code 99242

Modifiers that may be applicable to CPT 99242 include:

• Modifier 25 – Indicates a significant, separately identifiable evaluation and management service performed by the same physician on the same day as another service.
• Modifier GC – Indicates the service was performed by a resident under the direct supervision of a teaching physician.
• Modifier 24 – Represents an unrelated E/M service by the same physician within a postoperative period.
• Modifier 57 – Indicates that the consultation involved a decision for surgery.
• Modifier 99 – Used when multiple modifiers are necessary.
• Modifier FP – Identifies family planning services when applicable.
• Modifier 32 – Indicates a consultation mandated by a third party or external entity.

Check payer-specific policies and documentation requirements when using these modifiers.

Other relevant CPT codes

Other related codes for outpatient services and evaluation and management include:

• 99243–99245 – Higher-level outpatient consultations involving an examination and moderate level of medical decision-making, typically appropriate for more severe or complicated conditions. These codes are suitable for a consultation for a new or established patient referred for detailed evaluation and medical decision-making of low or moderate to high severity.
• 99202–99205 – Office visits for new patients, used when care does not involve a formal consultation request but requires detailed or comprehensive assessment.
• 99213–99215 – Office visits for established patients that reflect varying complexity levels. Unlike CPT 99242, these codes don't require documentation of a formal consultation request.
• 99341–99345 – Home or residence services provided to new patients, distinct from office-based consultations like CPT 99242.
• 99417 – Prolonged services code for outpatient E/M, each 15 minutes