CPT® Code 99245: Office Consultation for New or Established Patient

CPT® code 99245 is used to report a comprehensive office consultation for a new or established patient that requires high-complexity medical decision-making. This code is typically billed when a specialist evaluates a patient, provides a detailed assessment, and develops a treatment plan or management strategy.

When to Use CPT® Code 99245

• For comprehensive consultations involving extensive history, detailed examination, and high-complexity medical decision-making.
• When addressing complex medical issues requiring a specialist’s expertise.
• Applicable to both new and established patients referred for evaluation and management.
• Documentation should reflect thorough assessment, clinical reasoning, and personalized treatment plan.

Billing Requirements

• Typically involves 60 minutes of face-to-face time, though billing is primarily based on complexity rather than time alone.
• Documentation must include history, examination, medical decision-making, and patient counseling.
• Ensure all relevant ICD-10 codes supporting medical necessity are included.
• Consultation may be billed separately from procedures performed during the visit.

Common Clinical Scenarios

• A patient with multiple comorbidities is referred to a cardiologist for evaluation and management of heart disease.
• A primary care provider requests a comprehensive endocrine consultation for a patient with complex thyroid and metabolic concerns.
• An integrative or specialty clinic conducts an extensive assessment for a patient with chronic autoimmune conditions.

Streamline Consultation Documentation with OptiMantra

Accurate documentation and billing for CPT® 99245 are critical for compliance and reimbursement. OptiMantra’s EMR and practice management platform allows providers to capture detailed consultation notes, track medical decision-making, and generate clean claims. Specialty, integrative, and primary care practices can streamline complex consultation workflows, reduce administrative burden, and focus on delivering high-quality patient care.

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