CPT Code 99245: Office or Outpatient Consultation, High Complexity

What is office or outpatient consultation, high complexity (CPT 99245)?

CPT code 99245 is designated as an office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and a high level of medical decision-making.

Specialists typically use this code upon request of another provider for complex cases requiring detailed evaluation and treatment recommendations. Conditions often involve multiple comorbidities, uncertain diagnoses, or the need for extensive data review and care coordination. The consulting provider must document the request, perform the consultation, and communicate findings to the referring clinician.

CPT code 99245 documentation requirements

Good documentation is key when billing for CPT code 99245. Here’s a simple list of what you must include to meet the requirements and support your consultation service:

• Documentation of the request for consultation and referring provider.
• Comprehensive history and physical examination.
• High-complexity decision-making: multiple diagnoses, extensive data review, and risks.
• Clear assessment, recommendations, and communication back to the referring provider.

Covering all these areas can help ensure your billing is accurate, support medical necessity, and avoid reimbursement delays.

CPT code 99245 billing guidelines

If you’re planning to bill for a consultation visit, it’s important to know exactly how CPT code 99245 fits in. Let’s break down the key billing guidelines so you can code confidently and avoid common mistakes:

• CPT 99245, classified under office or outpatient consultation for new or established patient visit codes, includes services provided in settings such as the office, outpatient clinic, home or residence services, or the emergency department.
• When selecting the code based on total time spent on the encounter date, you must meet or go over 55 minutes.
• When the service involves transferring care for a patient's condition or overall health, the provider should use the right new or established patient visit codes instead of CPT 99245 for office visits, outpatient consultations, or home or residence services.
• Medicare no longer accepts consultation codes; use equivalent evaluation and management service codes as needed.
• Verify payer policies and coverage before using consultation codes.
• Ensure documentation supports all components, including medical necessity and consultation intent.

Following these CPT 99245 billing tips can help you stay compliant and get reimbursed properly.