CPT® code 99242 is used to report an outpatient consultation with a new or established patient that requires a medically appropriate history and/or examination and straightforward medical decision making (MDM). Alternatively, this code may be selected based on a total time of 20 minutes spent on the encounter on the date of the consultation.
Key components
CPT 99242 applies when a physician or other qualified healthcare professional is requested by another provider to evaluate or manage a specific medical issue in an outpatient setting. To qualify as a consultation, the service must be:
- Explicitly requested by another provider (e.g., a primary care provider referring to a specialist)
- Documented as a request for opinion or advice
- Followed by a consultation report back to the referring provider
This code reflects visits involving relatively straightforward problems—such as evaluation of a minor skin lesion, medication clarification, or second opinions on low-complexity conditions.
When to report CPT code 99242
You should report 99242 when:
- The visit is outpatient-based (e.g., in a clinic or office)
- A referral or request for consultation has been made and documented
- The visit involves straightforward MDM or 20 minutes of total time spent (including pre-visit review, face-to-face care, and post-visit documentation)
- You send a report back to the referring provider
Time-based coding and documentation
You can also bill 99242 based on time alone, as long as the total time on the date of the encounter is 20 minutes, and all time-based activities are documented. These may include:
- Reviewing records or test results
- Face-to-face patient interaction
- Counseling or coordination of care
- Post-visit documentation
Ensure your documentation reflects the total time spent and details the consultation request, services provided, and report back to the referring provider.
Optimize Consultations with OptiMantra
For integrative, specialty, and consult-heavy practices, OptiMantra’s EHR platform makes it easy to manage and document consultations that meet CPT 99242 requirements. Providers can:
- Track and document referrals directly in the patient chart
- Use specialty-specific templates to streamline history, exam, and MDM documentation
- Auto-generate consultation summaries for quick sharing with referring providers
- Link diagnoses and billing codes to ensure accurate claims
- Review payer-specific coding guidance within the system to reduce denials
With built-in tools designed for consultative workflows, OptiMantra helps providers stay compliant, efficient, and focused on patient care.
Try OptiMantra for free here!
